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Whitney R, Go C, Abushama A, Jain P. CNKSR2-Related Developmental and Epileptic Encephalopathy with Spike-Wave Activation in Sleep: A Report of Two Additional Cases and Review of the Literature. Neurol India 2024; 72:129-137. [PMID: 38443014 DOI: 10.4103/ni.ni_1191_21] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 06/14/2022] [Indexed: 03/07/2024]
Abstract
CNKSR2 variants have been associated with X linked intellectual disability and epilepsy including developmental and epileptic encephalopathy with spike wave activation in sleep (D/EE SWAS) in males. We aimed to describe a sibling pair with a novel pathogenic variant in CNKSR2 with D/EE SWAS and review published cases of D/EE SWAS. A retrospective chart review and a comprehensive review of the literature were conducted. Two brothers with a novel pathogenic variant in the CNKSR2 gene (c. 114delG, p.Ile39SerfsX14) were identified. The epilepsy phenotype was similar to previous cases and was characterized by early onset seizures, nocturnal seizures (focal motor with/without impaired awareness), global developmental delay and language impairment, frontal central temporal predominant epileptiform discharges with a spike wave index >95%, and treatment resistance. However, phenotypic variability was observed and the younger brother had milder neuro developmental impairment, and the diagnosis of D/EE SWAS was made by surveillance electro encephalogram (EEG). Literature search yielded 23 cases, and their clinical/neuro physiological features are discussed. To conclude, CNKSR2 related D/EE SWAS may be early onset and occur before the age of 5 years in some. Early surveillance EEG may aid in diagnosis. Phenotypic variability was observed in our cases as well as sibling pairs in the literature, which may impact genetic counseling.
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Affiliation(s)
- Robyn Whitney
- Department of Paediatrics, Division of Neurology, McMaster University, Hamilton, ON, Canada
| | - Cristina Go
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children (HSC), University of Toronto, Toronto, ON, Canada
| | - Ahmed Abushama
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children (HSC), University of Toronto, Toronto, ON, Canada
| | - Puneet Jain
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children (HSC), University of Toronto, Toronto, ON, Canada
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2
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Sunkonkit K, Go C, Alzaid M, Massicotte C, Narang I, Amin R. An Unusual Cause of Worsening Obstructive Sleep Apnea. Clin Pediatr (Phila) 2023; 62:188-190. [PMID: 36016488 DOI: 10.1177/00099228221118957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kanokkarn Sunkonkit
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Pulmonary and Critical Care, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Cristina Go
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mohammed Alzaid
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Colin Massicotte
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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3
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Gettings JV, Shafi S, Boyd J, Snead OC, Rutka J, Drake J, McCoy B, Jain P, Whitney R, Go C. The Epilepsy Surgery Experience in Children With Infantile Epileptic Spasms Syndrome at a Tertiary Care Center in Canada. J Child Neurol 2023; 38:113-120. [PMID: 36788207 DOI: 10.1177/08830738231151993] [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: 02/16/2023]
Abstract
BACKGROUND Infantile epileptic spasms syndrome is an epileptic encephalopathy, characterized by spasms, hypsarrhythmia, and developmental regression. Appropriately selected patients with infantile epileptic spasms syndrome may be candidates for epilepsy surgery. METHODS This is a single-center retrospective case series of children 0-18 years with a current or previous diagnosis of infantile epileptic spasms syndrome with a lesion on magnetic resonance imaging (MRI) and/or positron emission tomography scan who underwent epilepsy surgery at The Hospital for Sick Children (HSC) in Toronto, Canada. The records of 223 patients seen in the infantile epileptic spasms syndrome clinic were reviewed. RESULTS Nineteen patients met inclusion criteria. The etiology of infantile epileptic spasms syndrome was encephalomalacia in 6 patients (32%), malformations of cortical development in 12 patients (63%), and atypical hypoglycemic injury in 1 patient (5%). Nine patients (47%) underwent hemispherectomy, and 10 patients (53%) underwent lobectomy/lesionectomy. Three patients (16%) underwent a second epilepsy surgery. Fifteen patients (79%) were considered ILAE seizure outcome class 1 (completely seizure free; no auras) at their most recent follow-up visit. The percentage of patients who were ILAE class 1 at most recent follow-up decreased with increasing duration of epilepsy prior to surgery. Developmental outcome after surgery was improved in 14 of 19 (74%) and stable in 5 of 19 (26%) patients. CONCLUSIONS Our study found excellent seizure freedom rates and improved developmental outcomes following epilepsy surgery in patients with a history of infantile epileptic spasms syndrome with a structural lesion detected on MRI brain. Patients who undergo surgery earlier have improved seizure freedom rates and improved developmental outcomes.
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Affiliation(s)
- Jennifer V Gettings
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - Shatha Shafi
- Division of Neurology, Department of Pediatrics, 37853Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Jennifer Boyd
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - James Rutka
- Division of Neurosurgery, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - James Drake
- Division of Neurosurgery, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - Bláthnaid McCoy
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - Puneet Jain
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada
| | - Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster Children's Hospital (McMaster University), Hamilton, ON, Canada
| | - Cristina Go
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children (University of Toronto), Toronto, Ontario, Canada.,Division of Neurology, Department of Pediatrics, British Columbia Children's Hospital (University of British Columbia), Toronto, Ontario, Canada
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Jain P, Sahu JK, Horn PS, Chau V, Go C, Mahood Q, Arya R. Treatment of children with infantile spasms: A network meta-analysis. Dev Med Child Neurol 2022; 64:1330-1343. [PMID: 35765990 DOI: 10.1111/dmcn.15330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/08/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 12/12/2022]
Abstract
AIM We performed a systematic review and network meta-analysis (NMA) to obtain comparative effectiveness estimates and rankings of non-surgical interventions used to treat infantile spasms. METHOD All randomized controlled trials (RCTs) including children 2 months to 3 years of age with infantile spasms (with hypsarrhythmia or hypsarrhythmia variants on electroencephalography) receiving appropriate first-line medical treatment were included. Electroclinical and clinical remissions within 1 month of starting treatment were analyzed. RESULTS Twenty-two RCTs comparing first-line treatments for infantile spasms were reviewed; of these, 17 were included in the NMA. Both frequentist and Bayesian network rankings for electroclinical remission showed that high dose adrenocorticotropic hormone (ACTH), methylprednisolone, low dose ACTH and magnesium sulfate (MgSO4 ) combination, low dose ACTH, and high dose prednisolone were most likely to be the 'best' interventions, although these were not significantly different from each other. For clinical remission, low dose ACTH/MgSO4 combination, high dose ACTH (with/without vitamin B6 ), high dose prednisolone, and low dose ACTH were 'best'. INTERPRETATION Treatments including ACTH and high dose prednisolone are more effective in achieving electroclinical and clinical remissions for infantile spasms. WHAT THIS PAPER ADDS Adrenocorticotropic hormone and high dose prednisolone are more effective than other medications for infantile spasms. Symptomatic etiology decreases the likelihood of remission even after adjusting for treatment lag.
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Affiliation(s)
- Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jitendra K Sahu
- Pediatric Neurology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Paul S Horn
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vann Chau
- Neonatal Neurology Program, Division of Neurology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cristina Go
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Quenby Mahood
- Hospital Library and Archives, Learning Institute, Toronto, ON, Canada
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Warsi NM, Yan H, Wong SM, Yau I, Breitbart S, Go C, Gorodetsky C, Fasano A, Kalia SK, Rutka JT, Vaughan K, Ibrahim GM. Vagus Nerve Stimulation Modulates Phase-Amplitude Coupling in Thalamic Local Field Potentials. Neuromodulation 2022; 26:601-606. [PMID: 35840521 DOI: 10.1016/j.neurom.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/26/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The antiseizure effects of vagus nerve stimulation (VNS) are thought to be mediated by the modulation of afferent thalamocortical circuitry. Cross-frequency phase-amplitude coupling (PAC) is a mechanism of hierarchical network coordination across multiple spatiotemporal scales. In this study, we leverage local field potential (LFP) recordings from the centromedian (CM) (n = 3) and anterior (ATN) (n = 2) nuclei in five patients with tandem thalamic deep brain stimulation and VNS to study neurophysiological changes in the thalamus in response to VNS. MATERIALS AND METHODS Bipolar LFP data were recorded from contact pairs spanning target nuclei in VNS "on" and "off" states. RESULTS Active VNS was associated with increased PAC between theta, alpha, and beta phase and gamma amplitude in CM (q < 0.05). Within the ATN, PAC changes also were observed, although these were less robust. In both nuclei, active VNS also modulated interhemispheric bithalamic functional connectivity. CONCLUSIONS We report that VNS is associated with enhanced PAC and coordinated interhemispheric interactions within and between thalamic nuclei, respectively. These findings advance understanding of putative neurophysiological effects of acute VNS and contextualize previous animal and human studies showing distributed cortical synchronization after VNS.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simeon M Wong
- Department of Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kerry Vaughan
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Department of Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada.
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Maruyama S, Jain P, Parbhoo K, Go C, Shibata T, Otsubo H. Prolonged Video-EEG and Heart Rate Variability can Elucidate Autonomic Dysregulation in Infantile Apneic Seizures. Pediatr Neurol 2022; 127:48-55. [PMID: 34959160 DOI: 10.1016/j.pediatrneurol.2021.11.007] [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] [Received: 08/11/2021] [Revised: 11/06/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Infantile apneic seizures (IASs) are unexpected life-threatening events. We aimed to determine the utility of prolonged video-electroencephalography (vEEG) and heart rate variability (HRV) in IAS. METHODS The study included seven infants with apneic seizures captured by vEEG, percutaneous oxygen saturation (SpO2), and electrocardiography (ECG). Interictal, preictal, and postictal HRV of patients and N2 sleep HRV of 10 age-matched controls were determined. RESULTS We analyzed seven vEEGs (duration = 17 to 87 hours) of seven patients aged three to 13 months (mean onset age of apneic event = 6.3 months). Fifteen apneic seizures (one to five per infant) were captured. The initial apneic seizure was captured at 7.5 to 76 hours (mean = 36.6 hours) after vEEG initiation. Ictal rhythmic delta/theta/fast waves were seen over temporal (five patients), central (one), and diffuse areas (one). Ictal SpO2 decreased between 1.5% and 90% (mean = 47.9%). Ictal decreased heart rate (HR) (six seizures) and ictal increased HR (14) was detected. Both decreased and increased HR was observed (five). The preictal low-frequency (LF)/high-frequency (HF) ratio was significantly higher than the interictal LF/HF ratio (P = 0.048). Preictal (P = 0.048), and postictal (P = 0.019) root mean square of successive differences (RMSSDs) of patients were lower than the sleep RMSSD of controls. These results indicated dominant sympathetic activity. RMSSD from interictal to preictal periods tended to be higher in IAS with decreased HR than in IAS with increased HR alone (P = 0.066). The postictal RMSSD showed tendency to be higher in IAS with decreased HR than in IAS with increased HR alone (P = 0.088). The decreased HR and increased RMSSD suggested not only sympathetic activity but also escalated parasympathetic activity in IAS. CONCLUSIONS Infants with unexpected apneic events should be monitored with prolonged vEEG, SpO2, and ECG. Abnormal HRV in infants with apneic seizures might indicate additional autonomic dysregulation in IAS.
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Affiliation(s)
- Shinsuke Maruyama
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Puneet Jain
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kaajal Parbhoo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Takashi Shibata
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Tamura G, Lo WB, Yau I, Vaughan KA, Go C, Singleton WG, Hazon D, Yan H, Otsubo H, Donner EJ, Rutka JT, Ibrahim GM. Patient Characteristics Associated with Seizure Freedom after Vagus Nerve Stimulation in Pediatric Intractable Epilepsy: An Analysis of “Super-Responders”. Journal of Pediatric Epilepsy 2021. [DOI: 10.1055/s-0041-1739489] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractClinical responses to vagus nerve stimulation (VNS) therapy for intractable epilepsy can be unpredictable, and factors that predict response to therapy are elusive. Minority of children undergoing VNS achieve seizure freedom. The current study aimed to characterize this exceptional patient population, defined as “super-responders” (SRs). Retrospective data were collected from 150 children who underwent VNS at a single pediatric institution. The patients' mean age at VNS device implantation was 12.0 years (range, 3.09–17.9 years). Ten SRs (6.7%) were identified who achieved and maintained seizure freedom for longer than 1 year following implantation. The interval between epilepsy onset and VNS device implantation was significantly shorter in SRs than in the other children (mean epilepsy duration 5.72 vs. 8.44 years, respectively; p = 0.032). SRs also had a significantly shorter proportion of life with epilepsy compared with the other children (mean ratio of epilepsy duration to age at implantation 0.52 vs. 0.71, respectively; p = 0.023). SRs reported their seizure freedom relatively early (six patients within 6 months and all patients within 12 months after implantation) at relatively low device settings (mean output current 0.81 mA at their last follow-up). Compared with conventional models, responsive VNS models with autostimulation features did not increase the ratio of SRs. No other clinical or imaging characteristic difference between SRs and the other children was found in this cohort. The current study showed a significant association between shorter epilepsy duration and shorter proportion of life with epilepsy and seizure freedom after VNS.
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Affiliation(s)
- Goichiro Tamura
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - William B. Lo
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Ivanna Yau
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kerry A. Vaughan
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cristina Go
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - William G.B. Singleton
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - David Hazon
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth J. Donner
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - James T. Rutka
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George M. Ibrahim
- Division of Neurosurgery, University of Toronto, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Phillips NL, Shatil AS, Go C, Robertson A, Widjaja E. Resting-State Functional MRI for Determining Language Lateralization in Children with Drug-Resistant Epilepsy. AJNR Am J Neuroradiol 2021; 42:1299-1304. [PMID: 33832955 DOI: 10.3174/ajnr.a7110] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Task-based fMRI is a noninvasive method of determining language dominance; however, not all children can complete language tasks due to age, cognitive/intellectual, or language barriers. Task-free approaches such as resting-state fMRI offer an alternative method. This study evaluated resting-state fMRI for predicting language laterality in children with drug-resistant epilepsy. MATERIALS AND METHODS A retrospective review of 43 children with drug-resistant epilepsy who had undergone resting-state fMRI and task-based fMRI during presurgical evaluation was conducted. Independent component analysis of resting-state fMRI was used to identify language networks by comparing the independent components with a language network template. Concordance rates in language laterality between resting-state fMRI and each of the 4 task-based fMRI language paradigms (auditory description decision, auditory category, verbal fluency, and silent word generation tasks) were calculated. RESULTS Concordance ranged from 0.64 (95% CI, 0.48-0.65) to 0.73 (95% CI, 0.58-0.87), depending on the language paradigm, with the highest concordance found for the auditory description decision task. Most (78%-83%) patients identified as left-lateralized on task-based fMRI were correctly classified as left-lateralized on resting-state fMRI. No patients classified as right-lateralized or bilateral on task-based fMRI were correctly classified by resting-state fMRI. CONCLUSIONS While resting-state fMRI correctly classified most patients who had typical (left) language dominance, its ability to correctly classify patients with atypical (right or bilateral) language dominance was poor. Further study is required before resting-state fMRI can be used clinically for language mapping in the context of epilepsy surgery evaluation in children with drug-resistant epilepsy.
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Affiliation(s)
- N L Phillips
- From the Neurosciences and Mental Health Program (N.L.P., A.S.S., A.R., E.W.), The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Department of Psychology (N.L.P.)
| | - A S Shatil
- From the Neurosciences and Mental Health Program (N.L.P., A.S.S., A.R., E.W.), The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - C Go
- Division of Neurology (C.G., E.W.)
| | - A Robertson
- From the Neurosciences and Mental Health Program (N.L.P., A.S.S., A.R., E.W.), The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - E Widjaja
- From the Neurosciences and Mental Health Program (N.L.P., A.S.S., A.R., E.W.), The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Division of Neurology (C.G., E.W.)
- Department of Diagnostic Imaging (E.W.), The Hospital for Sick Children, Toronto, Ontario, Canada
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Warsi NM, Narvacan K, Donner E, Go C, Strantzas S, Ochi A, Otsubo H, Sharma R, Snead OC, Ibrahim GM. Supplementing Extraoperative Electrocorticography With Real-Time Intraoperative Recordings Using the Same Chronically Implanted Electrodes. Oper Neurosurg (Hagerstown) 2021; 20:559-564. [PMID: 33555026 DOI: 10.1093/ons/opab019] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The practice of intraoperative electrocorticography (iECoG) to guide resective epilepsy surgery is variable. Limitations of iECoG include variability in recordings from previously unsampled cortex, increased operative time and cost, and a lack of clear benefit to surgical decision-making. OBJECTIVE To describe a simple technique to supplement extraoperative intracranial recordings with real-time iECoG using the same chronically implanted electrodes that overcome some of these limitations. METHODS We describe the technical procedure, intraoperative findings, and outcomes of 7 consecutive children undergoing 2-stage resective epilepsy surgery with invasive subdural grid monitoring between January 2017 and December 2019. All children underwent placement of subdural grids, strips, and depth electrodes. Planned neocortical resection was based on extraoperative mapping of ictal and interictal recordings. During resection in the second stage, the same electrodes were used to perform real-time iECoG. RESULTS Real-time iECoG using this technique leads to modification of resection for 2 of the 7 children. The first was extended due to an electroencephalographic seizure from a distant electrode not part of the original resection plan. The second was restricted due to attenuation of epileptiform activity following a partial resection, thereby limiting the extent of a Rolandic resection. No infections or other adverse events were encountered. CONCLUSION We report a simple technique to leverage chronically implanted electrodes for real-time iECoG during 2-stage resective surgery. This technique presents fewer limitations than traditional approaches and may alter intraoperative decision-making.
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Affiliation(s)
- Nebras M Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karl Narvacan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Donner
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roy Sharma
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- Department of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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10
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Suzuki H, Otsubo H, Yokota N, Nishijima S, Go C, Carter Snead O, Ochi A, Rutka JT, Moharir M. Epileptogenic modulation index and synchronization in hypsarrhythmia of West syndrome secondary to perinatal arterial ischemic stroke. Clin Neurophysiol 2021; 132:1185-1193. [PMID: 33674213 DOI: 10.1016/j.clinph.2020.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/17/2020] [Revised: 11/30/2020] [Accepted: 12/14/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Perinatal arterial ischemic stroke (PAIS) is associated with epileptic spasms of West syndrome (WS) and long term Focal epilepsy (FE). The mechanism of epileptogenic network generation causing hypsarrhythmia of WS is unknown. We hypothesized that Modulation index (MI) [strength of phase-amplitude coupling] and Synchronization likelihood (SL) [degree of connectivity] could interrogate the epileptogenic network in hypsarrhythmia of WS secondary to PAIS. METHODS We analyzed interictal scalp electroencephalography (EEG) in 10 WS and 11 FE patients with unilateral PAIS. MI between gamma (30-70 Hz) and slow waves (3-4 Hz) was calculated to measure phase-amplitude coupling. SL between electrode pairs was analyzed in 9-frequency bands (5-delta, theta, alpha, beta, gamma) to examine inter- and intra-hemispheric connectivity. RESULTS MI was higher in affected hemispheres in WS (p = 0.006); no differences observed in FE. Inter-hemispheric SL of 3-delta, theta, alpha, beta, gamma bands was significantly higher in WS (p < 0.001). In WS, modified Z-Score of intra-hemispheric SL values in 3-delta, theta, alpha, beta and gamma in the affected hemispheres were significantly higher than those in the unaffected hemispheres (p < 0.001) as well as 0.5-4 Hz (p = 0.004). CONCLUSIONS The significantly higher modulation in affected hemisphere and stronger inter- and intra-hemispheric connectivity generate hypsarrhythmia of WS secondary to PAIS. SIGNIFICANCE Epileptogenic cortical-subcortical transcallosal networks from affected hemisphere post-PAIS provokes infantile spasms.
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Affiliation(s)
- Hiroharu Suzuki
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Department of Neurosurgery, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
| | - Hiroshi Otsubo
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Nanako Yokota
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Sakura Nishijima
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Cristina Go
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - O Carter Snead
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Ayako Ochi
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Children's Stroke Program, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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11
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Yan H, Siegel L, Breitbart S, Gorodetsky C, Gonorazky HD, Yau I, Go C, Donner E, Kalia SK, Fasano A, Weil AG, Fallah A, Ibrahim GM. The Child & Youth CompreHensIve Longitudinal Database for Deep Brain Stimulation (CHILD-DBS). Childs Nerv Syst 2021; 37:607-615. [PMID: 32935233 DOI: 10.1007/s00381-020-04880-4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/04/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Deep brain stimulation (DBS) is a common tool for the treatment of movement disorders in adults; however, it remains an emerging treatment modality in children with a growing number of indications, including epilepsy and dystonia. The Child & Youth CompreHensIve Longitudinal Database of DBS (CHILD-DBS) study aims to prospectively collect relevant data on quality of life (QoL), safety, efficacy, and long-term neurodevelopmental outcomes following DBS in children. METHODS Data are collected and managed using the Research Electronic Data Capture (REDCap). This database aims to collect multicentre comprehensive and longitudinal clinical, QoL, imaging and electrophysiologic data for children under the age of 19 undergoing DBS. RESULTS Both general and indication-specific measures are collected at baseline and at four time points postoperatively: 6 months, 1 year, 2 years, and 3 years. The database encompasses QoL metrics for children, including the PedsQL (Pediatric Quality of Life Inventory, generic), QOLCE (Quality of Life in Childhood Epilepsy Questionnaire, parent-rated), CHU 9D (Child Health Utility 9D), and KIDSCREEN. Caregiver clinical and QoL metrics, including QIDS (Quick Inventory of Depressive Symptomatology), GAD-7 (Generalized Anxiety Disorder 7-item scale), and CarerQoL-7D (The Care-related Quality of Life Instrument), are similarly prospectively collected. Healthcare resource utilization is also assessed before and after DBS. Lastly, stimulation parameters and radiographic and electrophysiologic data are collected within the database. CONCLUSIONS The development of the current prospective paediatric DBS database with carefully selected physical and psychosocial outcomes and assessments will complement existing efforts to enhance and facilitate multisite collaboration to further understand the role of DBS in childhood.
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Affiliation(s)
- Han Yan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lauren Siegel
- Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hernan D Gonorazky
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Donner
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Alfonso Fasano
- Krembil Brain Institute, Toronto, Ontario, Canada.,Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Alexander G Weil
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Division of Neurosurgery and Pediatrics, Sainte Justine Hospital, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada. .,Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada. .,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
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12
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Hadjinicolaou A, Jain P, Arya R, Roth C, Whitney R, Yau I, Greiner HM, Mangano FT, Rutka JT, Go C. Generator replacement with cardiac-based VNS device in children with drug-resistant epilepsy: An observational study. Epilepsy Res 2020; 167:106431. [DOI: 10.1016/j.eplepsyres.2020.106431] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/02/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022]
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13
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Biswas A, Yossofzai O, Vincent A, Go C, Widjaja E. Vigabatrin-related adverse events for the treatment of epileptic spasms: systematic review and meta-analysis. Expert Rev Neurother 2020; 20:1315-1324. [PMID: 33078964 DOI: 10.1080/14737175.2020.1840356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Although vigabatrin (VGB) is effective and well tolerated for the treatment of epileptic spasms, there are safety concerns. The aim of this systematic review and metaanalysis was to assess adverse events of VGB for the treatment of epileptic spasms. Methods: MEDLINE, EMBASE, and Cochrane databases were searched. The population was infants treated with VGB for epileptic spasms. The outcomes were VGB-related adverse events. Meta-analyses of VGB-related MRI abnormalities, retinal toxicity as measured by electroretinogram (ERG), visual field defect as measured by perimetry, and other adverse events were conducted. Results: Fifty-seven articles were included in the systematic review. The rate of VGB-related MRI abnormalities was 21% (95% CI: 15-29%). Risk factors for MRI abnormalities were age younger than 12 months and higher VGB dose. VGB-related retinal toxicity and visual field defect occurred in 29% (95% CI: 7-69%) and 28% (95% CI: 4-78%) respectively. Other adverse events occurred in 23% (95% CI: 16-34%), consisting predominantly of central nervous system symptoms, and the majority of these did not require therapeutic modification. Conclusion: This study will inform physicians and families on the risk profile of VGB for the treatment of epileptic spasms and will help decisions on treatment options.
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Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto , Toronto, ON, Canada
| | - Omar Yossofzai
- Neuroscience and Mental Health, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Ajoy Vincent
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children , Toronto, Ontario, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, The Hospital for Sick Children , Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto , Toronto, ON, Canada.,Neuroscience and Mental Health, The Hospital for Sick Children , Toronto, Ontario, Canada.,Division of Neurology, The Hospital for Sick Children , Toronto, Ontario, Canada
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14
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Ba-Armah D, Jain P, Whitney R, Donner E, Drake J, Go C, Nair RR, Snead OC, Weiss S, Widjaja E, Yamamoto E, Ye A, Yamasaki H, Ochi A. Misleading Focal Clinical, Neurophysiologic, and Imaging Features in 2 Children With Generalized Epilepsy Who Underwent Invasive Electroencephalographic (EEG) Monitoring. J Child Neurol 2020; 35:418-424. [PMID: 32065003 DOI: 10.1177/0883073819901228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/15/2022]
Abstract
Children and adults with genetic generalized epilepsy may have focal clinical seizure symptoms as well as electroencephalographic (EEG) findings. This may pose a diagnostic challenge to clinicians, especially when concomitant focal neuroimaging findings exist and the epilepsy is medically refractory. We sought to highlight the challenges that clinicians may face through the description of 2 children with suspected genetic generalized epilepsy who had both focal seizure symptoms and EEG/neuroimaging findings and underwent invasive EEG monitoring. Ultimately, invasive monitoring failed to demonstrate a focal origin for the seizures in both cases, and instead confirmed the presence of genetic generalized epilepsy. We demonstrate that ≥3-Hz generalized monomorphic spike and waves are less likely to represent secondary bilateral synchrony, that focal neuroimaging findings may not always be causal and that repeated hyperventilation is an essential activation procedure for genetic generalized epilepsy.
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Affiliation(s)
- Duaa Ba-Armah
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Puneet Jain
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada.,Division of Pediatric Neurology, Department of Pediatrics, BLK Super Speciality Hospital, New Delhi, India
| | - Robyn Whitney
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Donner
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - James Drake
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
| | - Cristina Go
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | | | - O Carter Snead
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Shelly Weiss
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Elysa Widjaja
- Department of Diagnostic Imaging, The Hospital for Sick Children, and Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Eriko Yamamoto
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Annette Ye
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Haruka Yamasaki
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Ayako Ochi
- Epilepsy Program, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
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15
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Din F, Lalgudi Ganesan S, Akiyama T, Stewart CP, Ochi A, Otsubo H, Go C, Hahn CD. Seizure Detection Algorithms in Critically Ill Children: A Comparative Evaluation. Crit Care Med 2020; 48:545-552. [PMID: 32205601 DOI: 10.1097/ccm.0000000000004180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 11/27/2022]
Abstract
OBJECTIVES To evaluate the performance of commercially available seizure detection algorithms in critically ill children. DESIGN Diagnostic accuracy comparison between commercially available seizure detection algorithms referenced to electroencephalography experts using quantitative electroencephalography trends. SETTING Multispecialty quaternary children's hospital in Canada. SUBJECTS Critically ill children undergoing electroencephalography monitoring. INTERVENTIONS Continuous raw electroencephalography recordings (n = 19) were analyzed by a neurophysiologist to identify seizures. Those recordings were then converted to quantitative electroencephalography displays (amplitude-integrated electroencephalography and color density spectral array) and evaluated by six independent electroencephalography experts to determine the sensitivity and specificity of the amplitude-integrated electroencephalography and color density spectral array displays for seizure identification in comparison to expert interpretation of raw electroencephalography data. Those evaluations were then compared with four commercial seizure detection algorithms: ICTA-S (Stellate Harmonie Version 7; Natus Medical, San Carlos, CA), NB (Stellate Harmonie Version 7; Natus Medical), Persyst 11 (Persyst Development, Prescott, AZ), and Persyst 13 (Persyst Development) to determine sensitivity and specificity in comparison to amplitude-integrated electroencephalography and color density spectral array. MEASUREMENTS AND MAIN RESULTS Of the 379 seizures identified on raw electroencephalography, ICTA-S detected 36.9%, NB detected 92.3%, Persyst 11 detected 75.9%, and Persyst 13 detected 74.4%, whereas electroencephalography experts identified 76.5% of seizures using color density spectral array and 73.7% using amplitude-integrated electroencephalography. Daily false-positive rates averaged across all recordings were 4.7 with ICTA-S, 126.3 with NB, 5.1 with Persyst 11, 15.5 with Persyst 13, 1.7 with color density spectral array, and 1.5 with amplitude-integrated electroencephalography. Both Persyst 11 and Persyst 13 had sensitivity comparable to that of electroencephalography experts using amplitude-integrated electroencephalography and color density spectral array. Although Persyst 13 displayed the highest sensitivity for seizure count and seizure burden detected, Persyst 11 exhibited the best trade-off between sensitivity and false-positive rate among all seizure detection algorithms. CONCLUSIONS Some commercially available seizure detection algorithms demonstrate performance for seizure detection that is comparable to that of electroencephalography experts using quantitative electroencephalography displays. These algorithms may have utility as early warning systems that prompt review of quantitative electroencephalography or raw electroencephalography tracings, potentially leading to more timely seizure identification in critically ill patients.
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Affiliation(s)
- Farah Din
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Saptharishi Lalgudi Ganesan
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University, Okayama, Japan
| | - Craig P Stewart
- St. Joseph's Health Care London, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Ayako Ochi
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Hiroshi Otsubo
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cristina Go
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Program in Neurosciences & Mental Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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16
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Mithani K, Wong SM, Mikhail M, Pourmotabbed H, Pang E, Sharma R, Yau I, Ochi A, Otsubo H, Snead OC, Donner E, Go C, Widjaja E, Babajani-Feremi A, Ibrahim GM. Somatosensory evoked fields predict response to vagus nerve stimulation. Neuroimage Clin 2020; 26:102205. [PMID: 32070812 PMCID: PMC7026289 DOI: 10.1016/j.nicl.2020.102205] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/14/2022]
Abstract
There is a need to preoperatively identify children who will respond to VNS. There is similarity between the afferent vagus and median nerve projections to S1. Median nerve somatosensory evoked fields identify those who will respond to VNS.
There is an unmet need to develop robust predictive algorithms to preoperatively identify pediatric epilepsy patients who will respond to vagus nerve stimulation (VNS). Given the similarity in the neural circuitry between vagus and median nerve afferent projections to the primary somatosensory cortex, the current study hypothesized that median nerve somatosensory evoked field(s) (SEFs) could be used to predict seizure response to VNS. Retrospective data from forty-eight pediatric patients who underwent VNS at two different institutions were used in this study. Thirty-six patients (“Discovery Cohort”) underwent preoperative electrical median nerve stimulation during magnetoencephalography (MEG) recordings and 12 patients (“Validation Cohort”) underwent preoperative pneumatic stimulation during MEG. SEFs and their spatial deviation, waveform amplitude and latency, and event-related connectivity were calculated for all patients. A support vector machine (SVM) classifier was trained on the Discovery Cohort to differentiate responders from non-responders based on these input features and tested on the Validation Cohort by comparing the model-predicted response to VNS to the known response. We found that responders to VNS had significantly more widespread SEF localization and greater functional connectivity within limbic and sensorimotor networks in response to median nerve stimulation. No difference in SEF amplitude or latencies was observed between the two cohorts. The SVM classifier demonstrated 88.9% accuracy (0.93 area under the receiver operator characteristics curve) on cross-validation, which decreased to 67% in the Validation cohort. By leveraging overlapping neural circuitry, we found that median nerve SEF characteristics and functional connectivity could identify responders to VNS.
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Affiliation(s)
- Karim Mithani
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Simeon M Wong
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Haatef Pourmotabbed
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA; Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Elizabeth Pang
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Roy Sharma
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Ivanna Yau
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Ayako Ochi
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Hiroshi Otsubo
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - O Carter Snead
- Division of Neurology, Hospital for Sick Children, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Elizabeth Donner
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Cristina Go
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Elysa Widjaja
- Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
| | - Abbas Babajani-Feremi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, Memphis, TN, USA; Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - George M Ibrahim
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Division of Neurosurgery, Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Canada.
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17
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Mithani K, Mikhail M, Morgan BR, Wong S, Weil AG, Deschenes S, Wang S, Bernal B, Guillen MR, Ochi A, Otsubo H, Yau I, Lo W, Pang E, Holowka S, Snead OC, Donner E, Rutka JT, Go C, Widjaja E, Ibrahim GM. Connectomic Profiling Identifies Responders to Vagus Nerve Stimulation. Ann Neurol 2019; 86:743-753. [DOI: 10.1002/ana.25574] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Karim Mithani
- The Faculty of MedicineUniversity of Toronto Toronto Ontario Canada
| | - Mirriam Mikhail
- The Faculty of MedicineUniversity of Toronto Toronto Ontario Canada
| | | | - Simeon Wong
- Institute of Biomaterials and Biomedical EngineeringUniversity of Toronto Toronto Ontario Canada
| | - Alexander G. Weil
- Division of NeurosurgerySaint Justine University Hospital Center, University of Montreal Montreal, Quebec Canada
| | - Sylvain Deschenes
- Division of NeurosurgerySaint Justine University Hospital Center, University of Montreal Montreal, Quebec Canada
| | - Shelly Wang
- Division of Neurosurgery, Brain InstituteNicklaus Children's Hospital Miami FL
| | - Byron Bernal
- Department of RadiologyNicklaus Children's Hospital Miami FL
| | | | - Ayako Ochi
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - Hiroshi Otsubo
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - Ivanna Yau
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - William Lo
- Division of Neurosurgery, Hospital for Sick Children, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Elizabeth Pang
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - Stephanie Holowka
- Department of Diagnostic ImagingHospital for Sick Children Toronto Ontario Canada
| | - O. Carter Snead
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - Elizabeth Donner
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - James T. Rutka
- Division of Neurosurgery, Hospital for Sick Children, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
| | - Cristina Go
- Division of NeurologyHospital for Sick Children Toronto Ontario Canada
| | - Elysa Widjaja
- Department of Diagnostic ImagingHospital for Sick Children Toronto Ontario Canada
| | - George M. Ibrahim
- Institute of Biomaterials and Biomedical EngineeringUniversity of Toronto Toronto Ontario Canada
- Division of Neurosurgery, Hospital for Sick Children, Department of SurgeryUniversity of Toronto Toronto Ontario Canada
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18
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Nelson RL, Go C, Darwish R, Gao J, Parikh R, Kang C, Mahajan A, Habeeb L, Zalavadiya P, Patnam M. Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis. Tech Coloproctol 2019; 23:809-820. [PMID: 31273486 DOI: 10.1007/s10151-019-02029-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 02/04/2019] [Accepted: 06/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review. METHODS Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI. RESULTS Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes. CONCLUSIONS There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.
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Affiliation(s)
- R L Nelson
- Epidemiology/Biometry Division, University of Illinois School of Public Health, Chicago, IL, USA.
| | - C Go
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Darwish
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - J Gao
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - R Parikh
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - C Kang
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - A Mahajan
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - L Habeeb
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - P Zalavadiya
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
| | - M Patnam
- Honors College, University of Illinois at Chicago, Chicago, IL, USA
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Christian EA, Widjaja E, Ochi A, Otsubo H, Holowka S, Donner E, Weiss SK, Go C, Drake J, Snead OC, Rutka JT. Utility of depth electrode placement in the neurosurgical management of bottom-of-sulcus lesions: technical note. J Neurosurg Pediatr 2019; 24:1-9. [PMID: 31252382 DOI: 10.3171/2019.4.peds18639] [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] [Received: 10/20/2018] [Accepted: 04/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Small lesions at the depth of the sulcus, such as with bottom-of-sulcus focal cortical dysplasia, are not visible from the surface of the brain and can therefore be technically challenging to resect. In this technical note, the authors describe their method of using depth electrodes as landmarks for the subsequent resection of these exacting lesions. METHODS A retrospective review was performed on pediatric patients who had undergone invasive electroencephalography with depth electrodes that were subsequently used as guides for resection in the period between July 2015 and June 2017. RESULTS Ten patients (3-15 years old) met the criteria for this study. At the same time as invasive subdural grid and/or strip insertion, between 2 and 4 depth electrodes were placed using a hand-held frameless neuronavigation technique. Of the total 28 depth electrodes inserted, all were found within the targeted locations on postoperative imaging. There was 1 patient in whom an asymptomatic subarachnoid hemorrhage was demonstrated on postprocedural imaging. Depth electrodes aided in target identification in all 10 cases. CONCLUSIONS Depth electrodes placed at the time of invasive intracranial electrode implantation can be used to help localize, target, and resect primary zones of epileptogenesis caused by bottom-of-sulcus lesions.
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Affiliation(s)
- Eisha A Christian
- 1Department of Neurological Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Elysa Widjaja
- 2Department of Diagnostic Imaging, Division of Neuroradiology
| | - Ayako Ochi
- 3Department of Pediatrics, Division of Neurology; and
| | | | | | | | | | - Cristina Go
- 3Department of Pediatrics, Division of Neurology; and
| | - James Drake
- 4Department of Surgery, Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | - James T Rutka
- 4Department of Surgery, Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Gulati P, Jain P, Lou Smith M, Kerr E, Muthusami P, Shroff M, Whitney R, Carter Snead O, Go C. Reliability and safety of Etomidate speech test in children with drug resistant focal epilepsy. Epilepsy Res 2019; 156:106150. [PMID: 31239182 DOI: 10.1016/j.eplepsyres.2019.106150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/15/2019] [Revised: 05/18/2019] [Accepted: 06/09/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To review our experience with the Etomidate speech test (EST) for lateralizing language in children undergoing epilepsy surgery evaluation METHODS: This retrospective study included children (<18 years) with drug refractory focal epilepsy undergoing EST for bilateral or poorly reliable language representation on functional MRI. Data for consecutive children who underwent EST between January 2013 to June 2017 were reviewed. RESULTS Twenty-one children (mean age at EST, 13.1 ± 4.4 years) were studied, with 19-right hemispheric and 20 left hemispheric injections. Six patients had neurological co-morbidities. Duration of ipsilateral EEG slowing was sufficient for speech testing in all children with a single bolus of Etomidate per carotid artery. Language was lateralized to one hemisphere in 17 (80.9%) and bilateral in two cases. EST was unsuccessful in two patients because of diffuse EEG slowing. Contralateral transient frontal EEG slowing was seen in 14 (73.7%) cases. EST was well tolerated in all the patients. CONCLUSIONS The EST was found to be successful and safe in lateralizing language in most of our drug refractory pediatric epilepsy cohort.
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Affiliation(s)
- Pratima Gulati
- Pratima Gulati, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
| | - Puneet Jain
- Pratima Gulati, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada; Division of Pediatric Neurology, Department of Pediatrics, BL Kapur (BLK) Super Speciality Hospital, Pusa Road, New Delhi 110005 India.
| | - Mary Lou Smith
- Mary Lou Smith, Division of Neurology, The Hospital for Sick Children, Department of Psychology, University of Toronto, Ontario, M5G1X8, Canada.
| | - Elizabeth Kerr
- Division of Neurology, Department of Psychology, University of Toronto, M5G1X8, Ontario, Canada.
| | - Prakash Muthusami
- Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
| | - Manohar Shroff
- Neuroradiology, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
| | - Robyn Whitney
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
| | - O Carter Snead
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
| | - Cristina Go
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, M5G1X8, Canada.
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Tychkivska O, Go C, Korzhynskyy Y, Ostalska O. Asymmetric neonatal spasms as an early sign of brain malformation potentially caused by regular light alcohol consumption during the first 22 weeks of pregnancy, a clinical case report. Dev Period Med 2019. [PMID: 30954976 PMCID: PMC8522345 DOI: 10.34763/devperiodmed.20192301.1520] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Introduction: Epileptic spasms are seizures usually associated with a severe developmental epilepsy syndrome with onset in the first year of life, peaking between 3 and 10 months of age [12]. A variety of disorders can cause epileptic spasms, with the etiology driving management, prognosis, and overall outcome. Preexisting brain damage has been demonstrated in 60% to 90% of the cases reflecting pre-, peri-, or postnatal brain injury that may usually be determined by history and clinical neurologic examination. Cerebral malformations may account for up to 30% of the cases [2]. Prenatal alcohol exposure can permanently damage the brain, affecting important structures, such as the cerebellum, corpus callosum as well as specific cell populations in many other regions of the brain. No one knows what a "safe" amount of alcohol consumption during pregnancy may be[3]. Objective: The aim of this article is to present a clinical case of a large brain temporal lobe malformation which was recognized after a very early onset of spasms registered on video EEG-monitoring followed by MRI findings and to put forward the assumption that regular consumption of light alcoholic drinks even in low doses could contribute to irreversible brain damage in the fetus. PATIENTS AND METHODS Material and methods: All patient data were collected from the NICU and Newborn Pathology Department of Lviv City Children's Clinical Hospital Health Record Department, and included the hospital and clinic records by the staff neurologist, neurophysiologist, and pediatrician, as well as EEG records in the postneonatal period. The mother was interviewed to clarify the pregnancy course data. The mother's consent was obtained for publication. RESULTS Results: Asymmetric spasms, which were recognized as seizures on the 4th day of the child's life while recording video EEG, urged the physicians towards further diagnostic investigations. Primarily the child was diagnosed with neonatal abstinence syndrome on the 2nd day of life based on clinical and patient history data, but on the following day episodes of myoclonic jerks and jitteriness were noticed and video EEG monitoring started. Upon analysis of video- EEG, myoclonic seizures and spasms were reported showing asymmetry in the amplitude of ictal EEG. MRI was recommended and performed to explain focal EEG findings, and a large brain left temporal lobe malformation was seen. CONCLUSION Conclusions: Spasms in the form of seizures are rarely reported in the neonatal period. Their recognition has to lead to urgent brain imaging study to look for the underlying cause and to implement timely, appropriate corrections in the treatment strategy. Although brain malformations can have many causes, taking careful antenatal, perinatal and family history has ruled out many usual etiologies. Maternal alcohol consumption during pregnancy may potentially have contributed to the condition.
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Affiliation(s)
- Olha Tychkivska
- Department of Pediatrics and Neonatology, Lviv National Medical UniversityLviv, Ukraine,Olha Tychkivska Department of Pediatrics and Neonatology, Lviv National Medical University vul. Pohulianka 4a/5, Lviv 79 017, Ukraine phone: +38097 218 56 72
| | - Cristina Go
- Division of Paediatric Neurology, Epilepsy and Clinical Neurophysiology, the Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yuriy Korzhynskyy
- Department of Pediatrics and Neonatology, Lviv National Medical UniversityLviv, Ukraine
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Ahmed R, Rubinger L, Go C, Drake JM, Rutka JT, Carter Snead O, Widjaja E. Utility of additional dedicated high-resolution 3T MRI in children with medically refractory focal epilepsy. Epilepsy Res 2019; 143:113-119. [PMID: 29398181 DOI: 10.1016/j.eplepsyres.2018.01.002] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 11/28/2017] [Accepted: 01/02/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE In patients with medically refractory epilepsy and normal magnetic resonance imaging (MRI), high-resolution dedicated MRI may identify cryptic lesions. The aim of this study was to assess improvement in lesion detection and its impact on clinical management, using additional high-resolution dedicated 3T MRI in children with medically refractory epilepsy who had normal 3T epilepsy protocol MRI. MATERIALS AND METHODS Children who had resective epilepsy surgery and suspected focal cortical dysplasia (FCD) or normal 3T epilepsy protocol MRI were included. Those with other diagnosis on MRI including tumor and hippocampal sclerosis were excluded. Patients who had normal MRI on 3T epilepsy protocol underwent dedicated high-resolution 3T MRI through the epileptogenic zone, guided by video EEG, Magnetoencephalography and FDG-PET data. RESULTS 101 patients with at least 1 year follow-up were included. Twenty-nine of 44 (66%) patients who had normal epilepsy protocol MRI had a lesion identified on dedicated high-resolution MRI. The addition of dedicated high-resolution MRI to standard epilepsy protocol increased sensitivity from 53.1% (95%CI: 40%-66%) to 85.9% (95%CI: 75%-93%). Identified lesions were concordant to surgical resection in all patients and guided depth/strip electrode insertion in 20/25 (80%) patients who underwent staged resection. Dedicated MRI detected small deep seated lesions in 10/20 (50%), and guided depth electrodes placement, without which it would not be feasible, as the lobar location of epileptogenic zone from other non-invasive tests were not sufficiently precise. CONCLUSION Patients with non-lesional epilepsy on standard epilepsy protocol MR may benefit from high-resolution dedicated MRI to aid identification of an underlying lesion, which could impact surgical management and improve seizure control.
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Affiliation(s)
- Raheel Ahmed
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Luc Rubinger
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James M Drake
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Elysa Widjaja
- Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Jain P, Whitney R, Strantzas S, McCoy B, Ochi A, Otsubo H, Snead OC, Weiss S, Donner E, Pang E, Sharma R, Viljoen A, Keller A, Drake JM, Rutka JT, Go C. Intra-operative cortical motor mapping using subdural grid electrodes in children undergoing epilepsy surgery evaluation and comparison with the conventional extra-operative motor mapping. Clin Neurophysiol 2018; 129:2642-2649. [DOI: 10.1016/j.clinph.2018.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/31/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
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Jalloh I, Cho N, Nga VD, Whitney R, Jain P, Al-Mehmadi S, Yau I, Okura H, Widjaja E, Otsubo H, Ochi A, Donner E, McCoy B, Drake J, Go C, Rutka JT. The role of surgery in refractory epilepsy secondary to polymicrogyria in the pediatric population. Epilepsia 2018; 59:1982-1996. [DOI: 10.1111/epi.14556] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Ibrahim Jalloh
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
| | - Newton Cho
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
| | - Vincent D.W. Nga
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
- Division of Neurosurgery; National University Hospital; Singapore City Singapore
| | - Robyn Whitney
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Puneet Jain
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
- Division of Pediatric Neurology; Department of Pediatrics; BLK Super Speciality Hospital; New Delhi India
| | - Sameer Al-Mehmadi
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Ivanna Yau
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Hidehiro Okura
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
- Department of Neurosurgery; Juntendo University School of Medicine; Tokyo Japan
| | - Elysa Widjaja
- Division of Diagnostic Imaging; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Hiroshi Otsubo
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Ayako Ochi
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Elizabeth Donner
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - Blathnaid McCoy
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - James Drake
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
| | - Cristina Go
- Division of Neurology; The Hospital for Sick Children; The University of Toronto; Toronto Ontario Canada
| | - James T. Rutka
- Division of Neurosurgery; The Hospital for Sick Children; Department of Surgery; The University of Toronto; Toronto Ontario Canada
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25
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Morrison-Levy N, Go C, Ochi A, Otsubo H, Drake J, Rutka J, Weiss SK. Children with autism spectrum disorders and drug-resistant epilepsy can benefit from epilepsy surgery. Epilepsy Behav 2018; 85:200-204. [PMID: 30032808 DOI: 10.1016/j.yebeh.2018.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 04/17/2018] [Revised: 05/31/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this research was to evaluate a cohort of children with both autism spectrum disorder (ASD) and drug-resistant epilepsy (DRE) after epilepsy surgery to determine predictors of best outcome. METHODS Retrospective chart review was done for 29 children ages 2 to 18 years with ASD and DRE who had neurosurgical intervention for seizure management over 15 years at one institution. All subjects had at least 1 year of follow-up. Data abstraction included demographic information, seizure diagnosis, treatment, investigations, surgical intervention, neuropsychological assessment, and outcome. Statistical analysis software (SAS) was used for statistical analysis. Engel classification was used to assess seizure outcome. RESULTS Fifteen subjects had resective surgery. Fourteen had palliative surgery with vagal nerve stimulator (VNS) insertion (13) and corpus callosotomy (1). Of the 29 subjects, 35% had class I outcome (all in the resective group). When combining all subjects (resective and palliative), 66% of subjects benefited with class I-III outcomes. In the total cohort, age at time of surgery was significant, with class I outcome more frequently seen in the younger age group when compared with classes II-IV (p = 0.01). CONCLUSION A subset of children with ASD can benefit from resective surgery, and for those who are not candidates, a VNS can offer significant improvements in seizure control.
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Affiliation(s)
- Nadine Morrison-Levy
- Divison of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Cristina Go
- Divison of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Ayako Ochi
- Divison of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Hiroshi Otsubo
- Divison of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - James Drake
- Division of Neurosurgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - James Rutka
- Division of Neurosurgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Shelly K Weiss
- Divison of Neurology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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Meng Y, Voisin MR, Suppiah S, Merali Z, Moghaddamjou A, Alotaibi NM, Manicat-Emo A, Weiss S, Go C, McCoy B, Donner EJ, Rutka JT. Risk factors for surgical site infection after intracranial electroencephalography monitoring for epilepsy in the pediatric population. J Neurosurg Pediatr 2018; 22:31-36. [PMID: 29624147 DOI: 10.3171/2018.1.peds17476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 11/06/2022]
Abstract
OBJECTIVE Intracranial electroencephalography (iEEG) monitoring is an important method of identifying the seizure focus in patients with medically refractory epilepsy. While previous studies have demonstrated low rates of surgical complications, reported rates of surgical site infection (SSI) are highly variable. To date, no studies have specifically evaluated the patient or operative risk factors contributing to SSI. The goals of this study were to examine the rate of SSI after iEEG monitoring for epilepsy workup in pediatric patients and to determine the variables that might contribute to the development of SSI. METHODS A retrospective analysis of hospital charts at the Hospital for Sick Children was performed for all patients who had undergone iEEG monitoring between 2000 and 2016. Univariate and multivariate analyses were performed to look for statistically significant variables in relation to SSI. RESULTS Among 199 patients eligible for analysis, 8 (4.0%) developed SSIs within a period ranging from 21 to 51 days postoperatively. Univariate analysis yielded 4 factors related to SSI: number of people present in the operating room on electrode insertion (p = 0.02), length of insertion surgery (p = 0.04), previous operation at the same surgical site (p = 0.04), and number of depth electrodes inserted (p = 0.01). Multivariate analysis revealed that both the number of people present during the implant operation (OR 0.08, 95% CI 0.01-0.70) and the number of depth electrodes inserted (OR 3.52, 95% CI 1.44-8.59) independently contributed to SSI. CONCLUSIONS This is the largest case series and the first comprehensive review of both patient and operative risk factors in the development of SSI from iEEG monitoring in a pediatric population. The authors' institution had a lower rate of infection than those in most other studies, which could be explained by their protocol of administering intravenous antibiotics perioperatively and post-implant removal antibiotics for 14 days. The authors found a correlation between SSI and the number of people present during the implant operation, as well as the number of depth electrodes; both may contribute to breaks in sterility.
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Affiliation(s)
- Ying Meng
- 1Division of Neurosurgery, University of Toronto; and
| | | | | | - Zamir Merali
- 1Division of Neurosurgery, University of Toronto; and
| | | | | | | | | | | | | | | | - James T Rutka
- 1Division of Neurosurgery, University of Toronto; and.,3Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Ganesan SL, Stewart CP, Atenafu E, Ochi A, Otsubo H, Go C, Hahn CD. T74. Factors that reduce the accuracy of seizure identification using quantitative EEG displays. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Jain P, Whitney R, McCoy B, Ochi A, Otsubo H, Snead C, Weiss S, Donner E, Strantzas S, Pang E, Sharma R, Viljoen A, Go C. T22. Intra-operative motor mapping using subdural grid electrodes in children undergoing invasive EEG monitoring. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ba-Armah DM, Donner EJ, Ochi A, Go C, McCoy B, Snead C, Drake J, Jones KC. "Saved by the Bell": Near SUDEP during intracranial EEG monitoring. Epilepsia Open 2018; 3:98-102. [PMID: 29588994 PMCID: PMC5839318 DOI: 10.1002/epi4.12093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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] [Accepted: 11/18/2017] [Indexed: 01/13/2023] Open
Abstract
SUDEP is the sudden unexpected death of a person with epilepsy, when no structural or toxicological cause of death can be found. The majority of witnessed cases are reported to be preceded by a convulsive seizure and postictal hypoventilation. Here, we report an 8‐year‐old girl with drug‐resistant focal seizures secondary to a focal cortical dysplasia type IIb. While undergoing invasive intracranial monitoring with subdural and depth electrodes, she had a clinical apnea event recorded on video, followed by bradycardia, which required resuscitation. Her intracranial electroencephalogram (EEG) during the event showed diffuse slowing and attenuation of cortical activity, with bradycardia that responded to positive pressure ventilation with oxygen. This near SUDEP event was not preceded by either an electroclinical or electrographic seizure. This is the first report of a witnessed, near‐SUDEP event during intracranial monitoring. It emphasizes the fact that near‐SUDEP can occur without a preceding seizure.
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Affiliation(s)
- Duaa M Ba-Armah
- Pediatric Neurology/Epilepsy Department of Pediatrics King Abdullah Specialized Children Hospital, KASCH Riyadh Saudi Arabia
| | - Elizabeth J Donner
- Division of Neurology Department of Pediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Ayako Ochi
- Division of Neurology Department of Pediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Cristina Go
- Division of Neurology Department of Pediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Bláthnaid McCoy
- Division of Neurology Department of Pediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Carter Snead
- Division of Neurology Department of Pediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - James Drake
- Division of Neurosurgery Department of Surgery The Hospital for Sick Children Toronto Ontario Canada
| | - Kevin C Jones
- The Division of Neurology Department of Pediatrics McMaster Children's Hospital Hamilton Ontario Canada
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30
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Iimura Y, Jones K, Takada L, Shimizu I, Koyama M, Hattori K, Okazawa Y, Nonoda Y, Asano E, Akiyama T, Go C, Ochi A, Snead OC, Donner EJ, Rutka JT, Drake JM, Otsubo H. Strong coupling between slow oscillations and wide fast ripples in children with epileptic spasms: Investigation of modulation index and occurrence rate. Epilepsia 2018; 59:544-554. [PMID: 29315516 DOI: 10.1111/epi.13995] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Epileptic spasms (ES) often become drug-resistant. To reveal the electrophysiological difference between children with ES (ES+) and without ES (ES-), we compared the occurrence rate (OR) of high-frequency oscillations (HFOs) and the modulation index (MI) of coupling between slow and fast oscillations. In ES+, we hypothesized that (1) pathological HFOs are more widely distributed and (2) slow oscillations show stronger coupling with pathological HFOs than in ES-. METHODS We retrospectively reviewed 24 children with drug-resistant multilobar onset epilepsy, who underwent intracranial video electroencephalography prior to multilobar resections. We measured the OR of HFOs and determined the electrodes with a high rate of HFOs by cluster analysis. We calculated MI, which reflects the degree of coupling between HFO (ripple/fast ripple [FR]) amplitude and 5 different frequency bands of delta and theta activities (0.5-1 Hz, 1-2 Hz, 2-3 Hz, 3-4 Hz, 4-8 Hz). RESULTS In ES+ (n = 10), the OR(FRs) , the number of electrodes with high-rate FRs, and the MI(FRs & 3-4 Hz) in all electrodes were significantly higher than in ES- (n = 14). In both the ES+ and ES- groups, MI(ripples/FRs & 3-4 Hz) was the highest among the 5 frequency bands. Within the good seizure outcome group, the OR(FRs) and the MI(FRs & 3-4 Hz) in the resected area in ES+ were significantly higher than in ES- (OR[FRs] , P = .04; MI[FRs & 3-4 Hz] , P = .04). SIGNIFICANCE In ES+, the larger number of high-rate FR electrodes indicates more widespread epileptogenicity than in ES-. High values of OR(FRs) and MI(FRs & 3-4 Hz) in ES+ compared to ES- are a signature of the severity of epileptogenicity. We proved that ES+ children who achieved seizure freedom following multilobar resections exhibited strong coupling between slow oscillations and FRs.
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Affiliation(s)
- Yasushi Iimura
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin Jones
- Division of Neurology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lynne Takada
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Itsuki Shimizu
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Misaki Koyama
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kyoko Hattori
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yushi Okazawa
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yutaka Nonoda
- Pediatrics and Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Eishi Asano
- Pediatrics and Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University Hospital, Okayama, Japan
| | - Cristina Go
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth J Donner
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James M Drake
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
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Go C, Jain P, Whitney R. Extreme delta brushes in a 14-year old girl with anti-NMDAR encephalitis. Neurol India 2018; 66:536-538. [DOI: 10.4103/0028-3886.227316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Whitney R, AlMehmadi S, McCoy B, Yau I, Ochi A, Otsubo H, Weiss SK, Rutka J, Hazrati LN, Snead OC, Go C. The Fault in Their Stars-Accumulating Astrocytic Inclusions Associated With Clusters of Epileptic Spasms in Children With Global Developmental Delay. Pediatr Neurol 2017; 73:92-97.e3. [PMID: 28549652 DOI: 10.1016/j.pediatrneurol.2017.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 02/22/2017] [Accepted: 04/09/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The presence of cerebral astrocytic inclusions recently has been described in a subset of children with early-onset refractory epilepsy, with or without structural brain malformations, and varying degrees of developmental delay. METHODS We describe two new individuals with epilepsy with astrocytic inclusions and suggest that in some children this disorder may represent a unique hemispheric epilepsy. We review previously reported individuals with epilepsy with astrocytic inclusions. RESULTS Two children with early onset epilepsy with astrocytic inclusions had refractory clusters of epileptic spasms, developmental delay, abnormal neuroimaging, and hemispheric or diffuse interictal epileptiform discharges. In both children, the initial focal resection of the putative epileptogenic zone was unsuccessful and pathology failed to show astrocytic inclusions. Subsequently, both children underwent functional hemispherectomy due to ongoing clusters of epileptic spasms, and the presence of multilobar astrocytic inclusions was demonstrated. Postoperatively, both children have remained seizure free in the short-term with improved development. CONCLUSIONS We highlight that functional hemispherectomy may be required for seizure control in a select subset of children with clusters of epileptic spasms, astrocytic inclusions, and global developmental delay. Given the small number of documented patients, however, ongoing collaboration is needed to better understand the pathophysiology of this condition and determine the optimal way to diagnose and manage these children.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Sameer AlMehmadi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bláthnaid McCoy
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ivanna Yau
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shelly K Weiss
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Rutka
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lili-Naz Hazrati
- Division of Pathology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
OBJECTIVE Although epilepsy surgery is an effective treatment option, at least 20%-40% of patients can continue to experience uncontrolled seizures resulting from incomplete resection of the lesion, epileptogenic zone, or secondary epileptogenesis. Reoperation could eliminate or improve seizures. Authors of this study evaluated outcomes following reoperation in a pediatric population. METHODS A retrospective single-center analysis of all patients who had undergone resective epilepsy surgery in the period from 2001 to 2013 was performed. After excluding children who had repeat hemispherotomy, there were 24 children who had undergone a second surgery and 2 children who had undergone a third surgery. All patients underwent MRI and video electroencephalography (VEEG) and 21 underwent magnetoencephalography (MEG) prior to reoperation. RESULTS The mean age at the first and second surgery was 7.66 (SD 4.11) and 10.67 (SD 4.02) years, respectively. The time between operations ranged from 0.03 to 9 years. At reoperation, 8 patients underwent extended cortical resection; 8, lobectomy; 5, lesionectomy; and 3, functional hemispherotomy. One year after reoperation, 58% of the children were completely seizure free (International League Against Epilepsy [ILAE] Class 1) and 75% had a reduction in seizures (ILAE Classes 1-4). Patients with MEG clustered dipoles were more likely to be seizure free than to have persistent seizures (71% vs 40%, p = 0.08). CONCLUSIONS Reoperation in children with recurrent seizures after the first epilepsy surgery could result in favorable seizure outcomes. Those with residual lesion after the first surgery should undergo complete resection of the lesion to improve seizure outcome. In addition to MRI and VEEG, MEG should be considered as part of the reevaluation prior to reoperation.
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Affiliation(s)
- Osama Muthaffar
- Division of Neurology.,Division of Pediatrics, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | - Luc Rubinger
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Ontario, Canada; and
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Whitney R, AlMehmadi S, Go C, Ochi A, Otsubo H, Bradbury L, Jones K, Christian E, Rutka J, McCoy B. Spiders, ladybugs and bees: A case of unusual sensations in a child with cingulate epilepsy. Epilepsy Behav Case Rep 2017; 8:1-6. [PMID: 28603689 PMCID: PMC5451186 DOI: 10.1016/j.ebcr.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/14/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
Abstract
Cingulate epilepsy is a rare form of epilepsy. Seizures from the anterior cingulate may present with mood change, fear, hypermotor activity, and autonomic signs, while posterior cingulate seizures resemble temporal lobe seizures. We describe a child with cingulate epilepsy who experienced unpleasant/painful sensory phenomenon. The sensations were described as spiders crawling on his forehead/right leg, ladybugs causing right ear pain and bees stinging his head/right extremities. Unpleasant sensory phenomenon/pain are rarely reported in cingulate epilepsy. Recognizing the role of the cingulate in producing pain/unusual sensory phenomenon is important, and may have localizing value when evaluating children for epilepsy surgery.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sameer AlMehmadi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laura Bradbury
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin Jones
- Division of Pediatric Neurology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Eisha Christian
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Rutka
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bláthnaid McCoy
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Iimura Y, Jones K, Hattori K, Okazawa Y, Noda A, Hoashi K, Nonoda Y, Asano E, Akiyama T, Go C, Ochi A, Snead OC, Donner EJ, Rutka JT, Drake JM, Otsubo H. Epileptogenic high-frequency oscillations skip the motor area in children with multilobar drug-resistant epilepsy. Clin Neurophysiol 2017; 128:1197-1205. [PMID: 28521267 DOI: 10.1016/j.clinph.2017.03.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Subtotal hemispherectomy involves the resection of multiple lobes in children with drug-resistant epilepsy, skipping the motor area (MA). We determined epileptogenicity using the occurrence rate (OR) of high-frequency oscillations (HFOs) and the modulation index (MI), demonstrating strength of coupling between HFO and slow wave. We hypothesized that epileptogenicity increased over the multiple lobes but skipped the MA. METHODS We analyzed 23 children (14 subtotal hemispherectomy; 9 multilobar resections). Scalp video-EEG and magnetoencephalography were performed before surgery. We analyzed the OR(HFO) and MI(5 phases=0.5-8 Hz) on electrodes of total area, resection areas, and MA. We compared the data between good [International League Against Epilepsy (ILAE) class I-II] and poor (III-VI) seizure outcome groups. RESULTS ILAE class Ia outcome was achieved in 18 children. Among the MI(5 phases) in the resection areas, MI(3-4 Hz) was the highest. The OR(HFO) and MI(3-4 Hz) in both total area and resection areas were significantly higher in the good seizure outcome group than in the poor outcome group. The OR(HFO) and MI(3-4 Hz) in resection areas were significantly higher than in the MA. CONCLUSIONS Our patients with multilobar drug-resistant epilepsy showed evidence of multifocal epileptogenicity that specifically skipped the MA. SIGNIFICANCE This is the first study demonstrating that the electrophysiological phenotype of multifocal epilepsy specifically skips the MA using OR(HFO) and MI(3-4 Hz).
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Affiliation(s)
- Yasushi Iimura
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin Jones
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kyoko Hattori
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yushi Okazawa
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Atsuko Noda
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kana Hoashi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yutaka Nonoda
- Pediatrics and Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Eishi Asano
- Pediatrics and Neurology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Tomoyuki Akiyama
- Department of Child Neurology, Okayama University Hospital, Okayama, Japan
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ayako Ochi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth J Donner
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James M Drake
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Sheleg M, Yu Q, Go C, Wagner GC, Kusnecov AW, Zhou R. Decreased maternal behavior and anxiety in ephrin-A5 -/- mice. Genes Brain Behav 2016; 16:271-284. [PMID: 27535576 DOI: 10.1111/gbb.12319] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 07/28/2016] [Accepted: 08/13/2016] [Indexed: 12/24/2022]
Abstract
During development of the nervous system, molecular signals mediating cell-cell interactions play critical roles in the guidance of axonal growth and establishment of synaptic functions. The Eph family of tyrosine kinase receptors and their ephrin ligands has been shown to mediate neuronal interactions in the development of topographic axon projection maps in several brain regions, and the loss of Eph activities result in defects in select axonal pathways. However, effects of deficiencies of the Eph signals on animal behavior have not been well documented. In this study, we showed that inactivation of a ligand of the Eph receptors, ephrin-A5, resulted in defects in maternal behavior and alterations in anxiety. Female ephrin-A5 -/- mice show significant defects in nest building and pup retrieval. In addition, lower levels of anxiety were observed in both male and female null mice. These changes were not due to deficiencies in estradiol, progesterone or corticosterone levels. Our observations suggest that ephrin-A5 plays a key role in the development and/or function of neural pathways mediating mouse maternal care and anxiety.
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Affiliation(s)
- M Sheleg
- Departments of Chemical Biology, Susan Lehman-Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University
| | - Q Yu
- Departments of Chemical Biology, Susan Lehman-Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University
| | - C Go
- Departments of Chemical Biology, Susan Lehman-Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University
| | - G C Wagner
- Environmental & Occupational Health Sciences Institute, UMDNJ/RWJMS.,Department of Psychology, Rutgers University, Piscataway, NJ, USA
| | - A W Kusnecov
- Department of Psychology, Rutgers University, Piscataway, NJ, USA
| | - R Zhou
- Departments of Chemical Biology, Susan Lehman-Cullman Laboratory for Cancer Research, Ernest Mario School of Pharmacy, Rutgers University.,Environmental & Occupational Health Sciences Institute, UMDNJ/RWJMS
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Okanishi T, Akiyama T, Mayo E, Honda Y, Ueda-Kawada C, Nakajima M, Homma Y, Ochi A, Go C, Widjaja E, Chuang SH, Rutka JT, Drake J, Snead OC, Otsubo H. Magnetoencephalography spike sources interrelate the extensive epileptogenic zone of tuberous sclerosis complex. Epilepsy Res 2016; 127:302-310. [PMID: 27693986 DOI: 10.1016/j.eplepsyres.2016.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 03/15/2016] [Revised: 08/16/2016] [Accepted: 09/05/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We hypothesized that the extensive epileptic network in patients with tuberous sclerosis complex (TSC) manifests as clustered and scattered distributions of magnetoencephalography spike sources (MEGSS). METHODS We retrospectively analyzed pre-surgical MEG in 15 patients with TSC. We performed single moving dipole analysis to localize and classify clustered and scattered MEGSS. We compared the number of electrodes within the resected area (RA) and the proportions of clustered and scattered MEGSS within RA with the seizure outcome. RESULTS The number of electrodes within RA ranged from 29 to 83 (mean=51). The MEGSS were distributed over multiple lobes (3-8; mean=5.9) and bilaterally in 14 patients. Clusters of MEGSS ranged from 1 to 4 (mean=1.4). The number of MEGSS ranged in total from 28 to 139 (mean=70); in the clusters, 10-128 (mean=49); and in the scatters, 0-45 (mean=21). Four patients achieved an Engel class I surgical outcome, four, a class II outcome; five, a class III outcome; and two, a class IV outcome. The proportion of MEGSS ranged in total from 0 to 92% (mean=57%) within RA; 0-100% (mean=67%) in the resection hemisphere; 0-100% (mean=63%) in the clusters; and 0-81% (mean=28%) in the scatters. Univariate ordinal logistic regression analyses showed that the proportion of scattered MEGSS within RA (p=0.049) significantly correlated with seizure outcomes. Multivariate analyses using three covariates (number of electrodes, proportions of clustered and scattered MEGSS within RA) showed that only the proportion of scattered MEGSS within RA significantly correlated with seizure outcomes (p=0.016). SIGNIFICANCE MEG data showed a wide distribution of multilobar MEGSS in patients with TSC. The seizure outcome was not related to the clustered MEGSS within RA, since the grids were essentially planned to cover and resect the clustered MEGSS surrounding tubers. The maximal possible resection of scattered MEGSS correlated with improved seizure outcome in TSC. Some parts of the epileptogenic zone disrupted by multiple tubers did not have a sufficiently large area to produce clustered MEGSS. Although the wide distribution of scattered MEGSS is not interpreted as epileptogenic, they might be interrelated with clustered MEGSS to project a complex epilepsy network and be part of the extensive epileptogenic zones found in TSC.
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Affiliation(s)
- Tohru Okanishi
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada.
| | - Tomoyuki Akiyama
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada; Department of Child Neurology, Okayama University Hospital, PO Box 700, 0914 Okayama, Japan
| | - Ellen Mayo
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Yasunori Honda
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Chihiro Ueda-Kawada
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Midori Nakajima
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei-Hamamatsu General Hospital, PO Box 430, 8558, Hamamatsu, Shizuoka, Japan
| | - Ayako Ochi
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Elysa Widjaja
- Division of Diagnostic Imaging, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Sylvester H Chuang
- Division of Diagnostic Imaging, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - James T Rutka
- Division of Neurosurgery, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - James Drake
- Division of Neurosurgery, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, PO Box M5G, 1X8, Toronto, Ontario, Canada
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Chen TY, Lines D, Dickson C, Go C, Kirkwood RN, Langendijk P. Elevating glucose and insulin secretion by carbohydrate formulation diets in late lactation to improve post-weaning fertility in primiparous sows. Reprod Domest Anim 2016; 51:813-8. [PMID: 27548995 DOI: 10.1111/rda.12760] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/16/2016] [Indexed: 01/18/2023]
Abstract
Primiparous (P1) sows commonly lose excessive body reserves to meet energy requirements for maintenance and milk production during lactation, and consequently, post-weaning reproductive performance may be compromised. The present studies determined whether ad libitum feeding a glucogenic carbohydrate diet (CHO) during late lactation could stimulate insulin and glucose secretion (experiment 1) and improve subsequent litter size (experiment 2). For experiment 1, 15 P1 sows, and for experiment 2, 99 P1 sows (198.5 ± 2.7 kg) were allocated randomly according to suckled litter size (≥10 piglets), either to a CHO diet (14.3 MJ DE/kg, 19.8% crude protein) or a standard lactation diet (control; 14.2 DE MJ/kg, 19.5% crude protein) at 8 days before weaning. The CHO diet aimed to provide glucogenic content (extruded wheat, dextrose and sugar) as energy sources instead of fat sources without changing total dietary energy. Pre-prandial plasma glucose and insulin concentrations were not influenced by treatments. However, post-prandial plasma glucose and insulin concentrations and their peaks were both higher (p < .05) compared to the control treatment. Body weight loss during lactation was relatively low at 3%-4% for both treatments and did not differ between control and CHO treatments (-7.6 ± 1.6 vs -5.4 ± 1.2 kg; p > .05). Second litter size was not influenced by diet (p > .05), but the weaning-to-mating interval was shorter in CHO sows (p < .05). This study demonstrates that providing an enriched CHO diet in late lactation did influence post-weaning follicle growth but did not improve subsequent litter size. This may be due to the primiparous sows in this study not experiencing severe negative energy balance and there was no second litter syndrome in this farm which limited the ability of diet to improve sow fertility.
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Affiliation(s)
- T Y Chen
- South Australian Research and Development Institute, Roseworthy, SA, Australia.
| | - D Lines
- SunPork Farms, Stirling, SA, Australia
| | - C Dickson
- Lienert Australia, Roseworthy, SA, Australia
| | - C Go
- South Australian Research and Development Institute, Roseworthy, SA, Australia
| | - R N Kirkwood
- School of Animal and Veterinary Sciences, University of Adelaide, Roseworthy Campus, Roseworthy, SA, Australia
| | - P Langendijk
- South Australian Research and Development Institute, Roseworthy, SA, Australia
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Fraser S, Go C, Aniss A, Sidhu S, Delbridge L, Learoyd D, Clifton-Bligh R, Tacon L, Tsang V, Robinson B, Gill AJ, Sywak M. BRAFV600E Mutation is Associated with Decreased Disease-Free Survival in Papillary Thyroid Cancer. World J Surg 2016; 40:1618-24. [DOI: 10.1007/s00268-016-3534-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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40
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Kiehna EN, Widjaja E, Holowka S, Carter Snead O, Drake J, Weiss SK, Ochi A, Thompson EM, Go C, Otsubo H, Donner EJ, Rutka JT. Utility of diffusion tensor imaging studies linked to neuronavigation and other modalities in repeat hemispherotomy for intractable epilepsy. J Neurosurg Pediatr 2016; 17:483-90. [PMID: 26651159 DOI: 10.3171/2015.7.peds15101] [Citation(s) in RCA: 16] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Hemispherectomy for unilateral, medically refractory epilepsy is associated with excellent long-term seizure control. However, for patients with recurrent seizures following disconnection, workup and investigation can be challenging, and surgical options may be limited. Few studies have examined the role of repeat hemispherotomy in these patients. The authors hypothesized that residual fiber connections between the hemispheres could be the underlying cause of recurrent epilepsy in these patients. Diffusion tensor imaging (DTI) was used to test this hypothesis, and to target residual connections at reoperation using neuronavigation. METHODS The authors identified 8 patients with recurrent seizures following hemispherectomy who underwent surgery between 1995 and 2012. Prolonged video electroencephalography recordings documented persistent seizures arising from the affected hemisphere. In all patients, DTI demonstrated residual white matter association fibers connecting the hemispheres. A repeat craniotomy and neuronavigation-guided targeted disconnection of these residual fibers was performed. Engel class was used to determine outcome after surgery at a minimum of 2 years of follow-up. RESULTS Two patients underwent initial hemidecortication and 6 had periinsular hemispherotomy as their first procedures at a median age of 9.7 months. Initial pathologies included hemimegalencephaly (n = 4), multilobar cortical dysplasia (n = 3), and Rasmussen's encephalitis (n = 1). The mean duration of seizure freedom for the group after the initial procedure was 32.5 months (range 6-77 months). In all patients, DTI showed limited but definite residual connections between the 2 hemispheres, primarily across the rostrum/genu of the corpus callosum. The median age at reoperation was 6.8 years (range 1.3-14 years). The average time taken for reoperation was 3 hours (range 1.8-4.3 hours), with a mean blood loss of 150 ml (range 50-250 ml). One patient required a blood transfusion. Five patients are seizure free, and the remaining 3 patients are Engel Class II, with a minimum follow-up of 24 months for the group. CONCLUSIONS Repeat hemispherotomy is an option for consideration in patients with recurrent intractable epilepsy following failed surgery for catastrophic epilepsy. In conjunction with other modalities to establish seizure onset zones, advanced MRI and DTI sequences may be of value in identifying patients with residual connectivity between the affected and unaffected hemispheres. Targeted disconnection of these residual areas of connectivity using neuronavigation may result in improved seizure outcomes, with minimal and acceptable morbidity.
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Affiliation(s)
- Erin N Kiehna
- Division of Neurosurgery, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California and
| | | | | | | | - James Drake
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | - Eric M Thompson
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | | | | | - James T Rutka
- Pediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
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Rubinger L, Chan C, Andrade D, Go C, Smith ML, Snead OC, Rutka JT, Widjaja E. Socioeconomic status influences time to surgery and surgical outcome in pediatric epilepsy surgery. Epilepsy Behav 2016; 55:133-8. [PMID: 26773684 DOI: 10.1016/j.yebeh.2015.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 09/03/2015] [Revised: 11/04/2015] [Accepted: 12/05/2015] [Indexed: 10/22/2022]
Abstract
The aims of this study were to evaluate the influence of socioeconomic status (SES) on time-to-surgery (TTS) and surgical outcome in children with treatment-resistant epilepsy in a universal health care system. The cohort consisted of children who had undergone resective epilepsy surgery between 2001 and 2013 in Canada. The patients' postal codes were linked to Statistics Canada National Household Survey data to obtain dissemination area income, which was used to infer SES. Time-to-surgery was defined as the interval from date of epilepsy onset to date of surgery. Seizure outcome was classified using ILAE classification. The associations between SES and TTS, as well as SES and surgical outcome, were assessed. Two hundred eighty-four children who had epilepsy surgery were included. Patients in the lowest income quintile had a significantly higher TTS relative to the highest income quintile (β=0.121, p=0.044). There were no significant associations between income quintiles and seizure-free surgical outcome (odds ratio (OR)=0.746-1.494, all p>0.05). However, patients in the lowest income quintile had a significantly lower odds of an improvement in seizure frequency relative to the highest income quintile (OR=0.262, p=0.046). The TTS was not uniform across SES in spite of the existence of a universal health care system. This finding highlights the need to address social and economic barriers for epilepsy surgery to improve access to this potentially curative treatment. Those with lower SES had lower likelihood of improvement in seizure control following epilepsy surgery and may require additional support including social and financial support to mitigate the discrepancies in seizure control following surgery between SES levels.
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Affiliation(s)
- Luc Rubinger
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - Carol Chan
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - Danielle Andrade
- Division of Neurology, University Health Network, Toronto, Canada
| | - Cristina Go
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - Mary Lou Smith
- Department of Psychology, University of Toronto, Toronto, Canada
| | - O Carter Snead
- Division of Neurology, Hospital for Sick Children, Toronto, Canada
| | - James T Rutka
- Department of Neurosurgery, Hospital for Sick Children, Toronto, Canada
| | - Elysa Widjaja
- Division of Neurology, Hospital for Sick Children, Toronto, Canada; Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.
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Almuqbil M, Go C, Nagy LL, Pai N, Mamak E, Mercimek-Mahmutoglu S. New Paradigm for the Treatment of Glucose Transporter 1 Deficiency Syndrome: Low Glycemic Index Diet and Modified High Amylopectin Cornstarch. Pediatr Neurol 2015. [PMID: 26216499 DOI: 10.1016/j.pediatrneurol.2015.06.018] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Glucose transporter 1 deficiency syndrome is an autosomal, dominantly inherited neurometabolic disorder caused by mutations in the SLC2A1 gene. Decreased glucose transport into the brain results in seizures and cognitive dysfunction. The ketogenic diet is the treatment of choice, but complicated with compliance problems. Stabilization of blood glucose levels by low glycemic index diet and modified high amylopectin cornstarch would provide steady-state glucose transport into the brain to prevent seizures and cognitive dysfunction in patients with glucose transporter 1 deficiency syndrome as an alternative treatment. PATIENT We report a new glucose transporter 1 deficiency syndrome patient (c.988C>T; p. Arg330X in the SLC2A1) treated with modified high amylopectin cornstarch (Glycosade) and low glycemic index diet because of compliance problems with the ketogenic diet. She was diagnosed at 11.5 years of age and was treated with the ketogenic diet between ages 12 and 18 years. RESULTS She was started on modified high amylopectin cornstarch at bedtime and low glycemic index diet with meals and snacks every 3-4 hours. Within the first 6 months of therapy, she improved in her seizures and cognitive functions, but experienced compliance problems afterwards. Neuropsychological assessment was stable at 12 months of therapy. CONCLUSION This diet was easy to apply compared with the ketogenic diet and resulted in stable neuropsychological functioning of this glucose transporter 1 deficiency syndrome patient. Modified high amylopectin cornstarch and low glycemic index diet might be an alternative treatment in glucose transporter 1 deficiency syndrome patients with compliance problems to the ketogenic diet treatment, but additional patients should be treated to prove usefulness of this new treatment.
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Affiliation(s)
- Mohammed Almuqbil
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada; Division of Pediatric Neurology, Montreal Children's Hospital-McGill University Health Center, Montreal, Canada; Division of Pediatric Neurology, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Cristina Go
- Division of Neurology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Laura L Nagy
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada; Department of Clinical Dietetics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Nisha Pai
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada; Department of Clinical Dietetics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Eva Mamak
- Department of Psychology, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Saadet Mercimek-Mahmutoglu
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada; Genetics and Genome Biology Research Program, Research Institute, The Hospital for Sick Children, Toronto, Canada.
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Abstract
The Child Neurology Society/American Academy of Neurology practice parameter has recommended adrenocorticotropic hormone or vigabatrin in the short-term treatment of infantile spasms. When vigabatrin is unavailable or ineffective and adrenocorticotropic hormone is not a treatment option because of the prohibitive cost, other forms of corticosteroids have been considered in the treatment of infantile spasms. This retrospective study reviewed the Hospital for Sick Children's experience with the short-term effectiveness of prednisolone versus adrenocorticotropic hormone in patients with infantile spasms who have failed vigabatrin. The results showed that while adrenocorticotropic hormone was more likely to lead to short-term spasm freedom, there was no difference in the likelihood of longer-term spasm resolution without relapse. These findings can guide clinicians in the treatment of infantile spasms post vigabatrin failure.
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Affiliation(s)
- Kevin Jones
- The Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - O Carter Snead
- The Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer Boyd
- The Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cristina Go
- The Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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Widjaja E, Go C, McCoy B, Snead OC. Neurodevelopmental outcome of infantile spasms: A systematic review and meta-analysis. Epilepsy Res 2014; 109:155-62. [PMID: 25524855 DOI: 10.1016/j.eplepsyres.2014.11.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [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: 09/15/2014] [Revised: 11/03/2014] [Accepted: 11/11/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aims of this systematic review and meta-analysis were to assess (i) estimates of good neurodevelopmental outcome in infantile spasms (IS), (ii) if neurodevelopmental outcome has changed since the publication of the first guideline on medical treatment of IS in 2004 and (iii) effect of lead time to treatment (LTTT). METHODS The Medline, Embase, Cochrane, PsycINFO, Web of Science and Scopus databases, and reference lists of retrieved articles were searched. Studies inclusion criteria were: (i) >5 patients with IS, (ii) mean/median follow-up of >6 months, (iii) neurodevelopmental outcome, and (iv) randomized and observational studies. The data extracted included proportion of good neurodevelopmental outcome, year of publication, cryptogenic or symptomatic IS and LTTT. RESULTS Of the 1436 citations screened, 55 articles were included in final analysis, with a total of 2967 patients. The pooled estimate for good neurodevelopmental outcome was 0.236 (95% CI: 0.193-0.286). There was no difference between the proportions of good neurodevelopmental outcome for the 21 studies published after 2004 [0.264 (95% CI: 0.197-0.344)] compared to the 34 studies published before 2004 [0.220 (95% CI: 0.168-0.283)] (Q value=0.862, p=0.353). The pooled estimate of good neurodevelopmental outcome for cryptogenic IS [0.543 (95% CI: 0.458-0.625)] was higher than symptomatic IS [0.125 (95% CI: 0.09-0.171)] (Q value=69.724, p<0.001). Risk ratio of LTTT <4weeks relative to >4weeks for good neurodevelopmental outcome of 8 studies was 1.519 (95% CI: 1.064-2.169). CONCLUSION Neurodevelopmental outcome was overall poor in patients with IS and has not changed since the publication of first guideline on IS. Although cryptogenic IS has better prognosis than symptomatic IS, the outcome for cryptogenic IS remained poor. There was heterogeneity in neurodevelopmental outcome ascertainment methods, highlighting the need for a more standardized and comprehensive assessment of cognitive, behavioural, emotional and functional outcomes.
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Affiliation(s)
- Elysa Widjaja
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Cristina Go
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Blathnaid McCoy
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - O Carter Snead
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Okanishi T, Akiyama T, Tanaka SI, Mayo E, Mitsutake A, Boelman C, Go C, Snead OC, Drake J, Rutka J, Ochi A, Otsubo H. Interictal high frequency oscillations correlating with seizure outcome in patients with widespread epileptic networks in tuberous sclerosis complex. Epilepsia 2014; 55:1602-10. [PMID: 25196064 DOI: 10.1111/epi.12761] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Multiple tubers in patients with tuberous sclerosis complex (TSC) often are responsible for drug-resistant epilepsy. The complexity of the epileptic network formed by multiple tubers complicates localization of the epileptogenic zone that is needed to design a surgical treatment strategy. High frequency oscillations (HFOs) on intracranial video-electroencephalography (IVEEG) may be a valuable surrogate marker for the localization of the epileptogenic zone. The purpose of this study was to test the hypothesis that high occurrence rate (OR) of interictal HFOs can guide the localization of the epileptogenic zone. METHODS We analyzed the OR of interictal HFOs at 80-200 Hz (ripples) and >200 Hz (fast ripples, FRs). We divided OR of interictal HFOs between high and low rates by thresholding. We analyzed the correlation between seizure outcomes using Engel classification and the resection ratio of the seizure onset zone (SOZ), and high-OR HFOs using ordinal logistic regression analysis. RESULTS We collected 10 patients. The seizure outcomes resulted in Engel classification I in three patients, II in four, III in one, and IV in two. High-OR ripples (5-57 [mean 29] channels, 1-4 [2.8] lobes) and high-OR FRs (9-66 [mean 27] channels, 1-4 [2.6] lobes) were widely distributed. The resection ratio of SOZ did not show statistically significant correlation with the seizure outcome. The resection ratio of high-OR ripples showed statistically significant correlation with the seizure outcome (p = 0.038). The resection ratio of high-OR FRs showed statistically significant correlation with the seizure outcome (p = 0.048). SIGNIFICANCE The multiple extensive zones with high-OR HFOs suggest a complex and widespread epileptic network in patients with TSC. In a subset of TSC patients with drug-resistant epilepsy, resection of cortex with both interictal high-OR FRs and ripples on IVEEG correlated with a good seizure outcome.
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Affiliation(s)
- Tohru Okanishi
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Bennett-Back O, Ochi A, Widjaja E, Nambu S, Kamiya A, Go C, Chuang S, Rutka JT, Drake J, Snead OC, Otsubo H. Magnetoencephalography helps delineate the extent of the epileptogenic zone for surgical planning in children with intractable epilepsy due to porencephalic cyst/encephalomalacia. J Neurosurg Pediatr 2014; 14:271-8. [PMID: 25014323 DOI: 10.3171/2014.6.peds13415] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Porencephalic cyst/encephalomalacia (PC/E) is a brain lesion caused by ischemic insult or hemorrhage. The authors evaluated magnetoencephalography (MEG) spike sources (MEGSS) to localize the epileptogenic zone in children with intractable epilepsy secondary to PC/E. METHODS The authors retrospectively studied 13 children with intractable epilepsy secondary to PC/E (5 girls and 8 boys, age range 1.8-15 years), who underwent prolonged scalp video-electroencephalography (EEG), MRI, and MEG. Interictal MEGSS locations were compared with the ictal and interictal zones as determined from scalp video-EEG. RESULTS Magnetic resonance imaging showed PC/E in extratemporal lobes in 3 patients, within the temporal lobe in 2 patients, and in both temporal and extratemporal lobes in 8 patients. Magnetoencephalographic spike sources were asymmetrically clustered at the margin of PC/E in all 13 patients. One cluster of MEGSS was observed in 11 patients, 2 clusters in 1 patient, and 3 clusters in 1 patient. Ictal EEG discharges were lateralized and concordant with MEGSS in 8 patients (62%). Interictal EEG discharges were lateralized and concordant with MEGSS hemisphere in 9 patients (69%). Seven patients underwent lesionectomy in addition to MEGSS clusterectomy with (2 patients) and without (5 patients) intracranial video-EEG. Temporal lobectomy was performed in 1 patient and hemispherectomy in another. Eight of 9 patients achieved seizure freedom following surgery. CONCLUSIONS Magnetoencephalography delineated the extent of the epileptogenic zone adjacent to PC/E in patients with intractable epilepsy. Complete resection of the MEGSS cluster along with PC/E can provide favorable seizure outcomes.
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Alshafai L, Ochi A, Go C, McCoy B, Hawkins C, Otsubo H, Snead OC, Rutka J, Widjaja E. Clinical, EEG, MRI, MEG, and surgical outcomes of pediatric epilepsy with astrocytic inclusions versus focal cortical dysplasia. Epilepsia 2014; 55:1568-75. [PMID: 25169867 DOI: 10.1111/epi.12756] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Astrocytic inclusions (AIs) have been identified on histologic specimens of patients with early onset seizures, and the proteomic contents have been described. The aim of this study was to compare the clinical, electroencephalography (EEG), magnetoencephalography (MEG), magnetic resonance imaging (MRI), and surgical outcomes of AIs relative to focal cortical dysplasia (FCD). METHODS We assessed the clinical manifestations, semiology, ictal and interictal features on video-EEG, MEG, MRI features, and surgical outcomes of children with histologically proven AIs compared to FCD. RESULTS Six children had AIs and 27 had FCD. Children with AIs had an earlier age at seizure onset, periodic spasms (all children), and interictal epileptiform discharges consisting of a mixture of generalized or diffuse hemispheric slow waves, sharp waves, spikes and polyspikes. Children with FCD were less likely to have spasms (4/27 [15%]), and the morphology of the diffuse hemispheric or generalized discharges were different from those of AI, consisting of spike-and-waves, polyspike-and-waves, sharp-and-slow waves, and paroxysmal fast activity. Patients with AIs were less likely to have tightly clustered MEG spike sources (3/6 [50%] vs. 23/27 [85%]), and more likely to demonstrate abnormal sulcation and gyration pattern (4/6 [67%] vs. 2/27 [7%]) and gray matter heterotopia (2/6 [33%] vs. 0/27 [0%]) than patients with FCD. Four children with AIs had resection and two had biopsy but did not undergo resection. Children with AIs had lower rates of seizure freedom after surgery compared to FCD (1/4 [25%] vs. 15/27 [56%], respectively). SIGNIFICANCE Although there were some similarities between AIs and FCD, patients with AIs were more likely to present with early onset periodic spasms, have unusual interictal epileptiform discharges, abnormal sulcation, gyration pattern, and gray matter heterotopia, and were less likely to be seizure free following surgical resection relative to FCD. Further study with a larger sample size is needed to validate our findings.
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Affiliation(s)
- Laila Alshafai
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
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Sud S, Sadaka Y, Massicotte C, Smith ML, Bradbury L, Go C, Weiss SK. Memory consolidation in children with epilepsy: does sleep matter? Epilepsy Behav 2014; 31:176-80. [PMID: 24434309 DOI: 10.1016/j.yebeh.2013.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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: 09/18/2013] [Revised: 12/10/2013] [Accepted: 12/15/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Children with epilepsy have frequent sleep disturbance and challenges in learning and memory. There is little research on the consolidation of memory during sleep in this population. The goal of this pilot study was to determine whether children with epilepsy are able to consolidate memories better after a sleep versus wake period as has been demonstrated in typically developing children. METHODS This study was a prospective evaluation of children with epilepsy to determine if sleep improved episodic memory (using word lists) as compared with memory following a wake period of similar duration. The study was conducted in patients in the Epilepsy Monitoring Unit at a single academic health science center. In the sleep recall condition, the learning trials were presented in the evening, and delayed recall of the words was tested in the morning. In the wake condition, the learning took place in the morning, and the delayed recall took place later in the day. Subjects wore an actigraph to evaluate sleep/wake patterns. Data regarding the children's epilepsy, antiepileptic medications, and frequency of interictal epileptiform discharges were also documented. RESULTS Ten children (agd 8-17years) participated in the study. For the entire sample, recall after sleep was better than recall after awake (p=0.03), and 7 of the 10 children showed this effect. However, reanalyses removing an outlier showed no difference between the two recall conditions. The mean number of interictal epileptiform discharges was 8.8 during the recall after sleep and 7.8 during the recall after awake. Three children had seizures during the evaluation. CONCLUSION In this pilot study, we demonstrated that a small cohort of children with epilepsy, with similar interictal epileptiform discharges during sleep and wake, showed no advantage in memory for a word list after a period of sleep than after a period of being awake. This finding requires further study in a larger cohort. Poor memory consolidation during sleep may contribute to the cognitive deficits in children with epilepsy.
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Affiliation(s)
- Shama Sud
- Division of Neurology, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
| | - Yair Sadaka
- Pediatric Neurology Unit, Ben Gurion University, Soroka Medical Center of the Negev, Be'er Sheva 84101 Israel.
| | - Colin Massicotte
- Division of Respiratory Medicine, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
| | - Mary Lou Smith
- Dept. of Psychology, Division of Neurology, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
| | - Laura Bradbury
- Division of Neurology, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
| | - Cristina Go
- Division of Neurology, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
| | - Shelly K Weiss
- Division of Neurology, University of Toronto, Hospital for Sick Children, 555 University Ave., Toronto, ON M5G1X8, Canada.
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Hanaya R, Okamoto H, Fujimoto A, Ochi A, Go C, Snead CO, Widjaja E, Chuang SH, Kemp SM, Otsubo H. Total intravenous anesthesia affecting spike sources of magnetoencephalography in pediatric epilepsy patients: Focal seizures vs. non-focal seizures. Epilepsy Res 2013; 105:326-36. [DOI: 10.1016/j.eplepsyres.2013.02.013] [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] [Received: 07/21/2012] [Revised: 12/29/2012] [Accepted: 02/27/2013] [Indexed: 01/24/2023]
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Widjaja E, Skocic J, Go C, Snead OC, Mabbott D, Smith ML. Abnormal white matter correlates with neuropsychological impairment in children with localization-related epilepsy. Epilepsia 2013; 54:1065-73. [PMID: 23650911 DOI: 10.1111/epi.12208] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE The white matter (WM) is considered critical for linking cortical processing networks necessary for cognition. The aim of this study was to assess diffusion tensor imaging (DTI) measures of regional WM in children with nonlesional localization-related epilepsy in comparison to controls, and to determine the relation between lobar WM and neuropsychological performance. METHODS Forty children with nonlesional localization-related epilepsy and 25 healthy controls with no neurological or psychiatric disorders and normal magnetic resonance imaging (MRI) were recruited. All patients and controls underwent neuropsychological testing that evaluated intelligence, language, memory, executive function, and motor function, as well as DTI to assess regional WM measures of fractional anisotropy (FA) and mean diffusivity (MD). The regional FA and MD were compared between patients and controls, and correlated with neuropsychological function. The relations between regional FA and MD with age at seizure onset and duration of epilepsy were assessed. KEY FINDINGS Twenty-one patients had left-sided and 19 patients had right-sided epilepsy. There were no significant differences in seizure-related variables including age at seizure onset, duration of epilepsy, seizure frequency, and number of antiepileptic medications, as well as no significant differences in neuropsychological function and DTI measures of white matter in left-sided compared to right-sided epilepsy. Therefore, all the patients with epilepsy were treated as one group. Patients with epilepsy performed significantly worse on intelligence (p < 0.001), language (p < 0.001), and executive function (p = 0.001) evaluation than controls. Patients had significantly reduced FA in left frontal (p = 0.015), right frontal (p = 0.004), left temporal (p = 0.039), right temporal (p = 0.003), right parietal (p = 0.014), and right occipital (p = 0.025) WM relative to controls. There were no significant regional WM differences (all p > 0.05) in MD between patients and controls. There was a significant positive correlation between right temporal FA with language (r = 0.535, p < 0.001) and executive function (r = 0.617, p < 0.001), as well as between body of corpus callosum FA with intelligence (r = 0.536, p < 0.001) and language (r = 0.529, p < 0.001) in patients. Left parietal MD was significantly correlated with language (r = -0.545, p < 0.001) in patients. FA of right temporal WM was significantly associated with age at seizure onset (t = 4.97, p < 0.001). SIGNIFICANCE There was widespread regional WM abnormality in children with nonlesional localization-related epilepsy, which was associated with impaired neuropsychological function. The impairment in WM may reflect disruption in the connectivity for cortical processing networks, which is necessary for the development of cognition.
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Affiliation(s)
- Elysa Widjaja
- Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada.
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