dravet syndrome: diagnosis history seizure evolution 1 linda laux, md pediatric epileptologist lurie...
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Dravet Syndrome:DiagnosisHistorySeizure Evolution
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Linda Laux, MDPediatric EpileptologistLurie Children’s Epilepsy CenterNorthwestern University Feinberg School of Medicine
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DISCLOSURES• Salary support from Dravet Syndrome Foundation for
Predictive Factors for Long-TermCognitive Outcome in Dravet Syndrome
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Dravet Syndrome (DS)• Epilepsy syndrome with intractable seizures and
cognitive/motor/behavior concerns that is highly associated with a sodium channel receptor mutation
• Clinical diagnosis of DS:– Seizure onset < 12 months of age– Prior to seizure onset: unremarkable PMHx, normal
development, normal neuroimaging– Seizures• Pleomorphic seizure types
– Generalized (GTC, myoclonic, atypical absence)– Focal (alternating unilateral hemiconvulsions, other)
– Developmental issues (slowing/plateau/regression)– Co-morbidity: Ataxia/gait abnormalities, behavioral
issues
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Historical Overview• Charlotte Dravet: recognized the clinical
constellation of this epilepsy syndrome [Dravet, Vie Medicale 1978]• Studying children with Lennox-Gastaut syndrome• Group of children were different• Initial normal development, history• Seizure onset in the first year of life, often as febrile
convulsions• Primarily clonic and myoclonic seizures • Seizures treatment resistant• Cognitive, behavior problems• No brain lesions
• New syndrome: Severe Myoclonic Epilepsy of Infancy (SMEI)• Publications
– 1978: “Les epilepsies graves de l’enfant”– 1982: “Advances in Epileptology: the XIIIth Epilepsy
International Symposium
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Historical Overview• Severe Myoclonic Epilepsy in Infancy: Variants
– Severe Myoclonic Epilepsy Borderline (borderland) [SMEB]– Intractable Childhood Epilepsy with GTC seizures [ICE-
GTC]• Identification of high association with SCN1A
mutation• Identification of SCN1A mutation with epilepsy (GEFS+)
[Escayg, Nat Genet. 2000]– Association of SCN1A mutation with Dravet syndrome
[Claes, Am J Hum Genetic 2001]• Seven patients with de novo SCN1A mutations (no
mutations in 184 control chromosomes
• “SMEI” not the best name• Children not “severe” in infancy • Not all the children have myoclonic seizures.
• Dravet syndrome• Dravet Syndrome Spectrum
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Dravet Syndrome: The First Seizure• Seizure onset:
– Less than one year of age: mean 6 month• Seizure semiology (description):
– Convulsive seizure (clonic >> tonic clonic)• Generalized, unilateral (hemiconvulsions)
– Less likely: complex partial, myoclonic– May be prolonged (status epilepticus)– Seizure Trigger: fever, vaccinations• Normal development, examination• Normal MRI and EEG• Typical initial diagnosis: (Complex) febrile seizures– No medication begun (+/- Diastat)
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Dravet Syndrome: The First Year• Seizures:
– Semiology:• Convulsive seizure (clonic >> tonic clonic)
– Generalized– Alternating unilateral clonic seizures
(hemiconvulsions)• Less frequent: complex partial, myoclonic
– Duration: prolonged– Frequency: Not frequent• Triggers: fever (low), vaccinations, hyperthermia,
abrupt change in temperature• Normal development (majority)
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Dravet Syndrome: Childhood• Very active seizure phase
– Seizures more varied– Seizure frequency markedly increases• Multiple medication/treatment trials
– Seizures initially still prolonged• Less prolonged seizures (status epilepticus)
over time• With active seizure phase, developmental,
cognitive, motor, behavioral concerns develop (1-5 years)• EEG becomes abnormal:
– Background slowing– Generalized and multifocal interictal
spikes/sharps
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Interictal EEG
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Dravet Syndrome: Varied Seizure Types
Convulsive and focal seizures–Convulsive (clonic >> tonic clonic)• Generalized, unilateral • May have preserved consciousness with unilateral
–Focal seizures• From any brain region
–Atypical convulsive seizures with both generalized and focal components• Any variation: stiffness (body turning), clonic jerks • Asymmetric, asynchronous, focal• EEG with generalized and focal features during the
seizures• In some literature: “falsely generalized”, “unstable
seizures”Triggers: Fever, vaccinations, hyperthermia, abrupt change in temperature, excitement
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Dravet Syndrome
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Dravet Syndrome
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Dravet Syndrome
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DS: Varied Seizure TypesNonconvulsive Seizures:–Atypical absence• 5-20 seconds (but may be prolonged)• Often with myoclonic jerks (head nods, eye
blinks)–Myoclonic seizures• Quick muscle jerks• Whole body, head drops, extremities
–Eyelid flutters: +/- EEG correlate–“Obtundation State”• Prolonged nonconvulsive seizure (atypical
absence, myoclonic)Triggers: photic stimulation, visual patterns, concentration, fine motor skills, tired, excitement
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Eyelid flutter
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Myoclonic seizure
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Myoclonic Seizure
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Myoclonic seizure
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Atypical absence seizure
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Dravet Syndrome: Adolescent, Adults• “Stabilize”
– Less frequent (although seizure control can worsen pre-teens/teenagers)
– Decreased incidence of prolonged seizures– However, limited literature• Adults
– Brief nocturnal “convulsions” most common seizure type [Jansen, Neurology 2006, Akiyama, Epilepsia 2010]
– Refractory to medications/treatment• Adults: 16% seizure free > 1 year (5/31 patients)
[Akiyama, Epilepsia 2010]
• Adults: 8% seizure free > 1 year (5/64 patients) [Tayayama, Epilepsia, 2014]
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General characteristics seizures in Dravet syndrome
1. Mixed seizure types– Both generalized and focal seizures• Generalized: convulsions, myoclonic atypical
absence• Focal: hemiconvulsions, other• Seizures with both generalized and focal
features– Treatment:• Broad spectrum medication useful for
generalized and focal seizures• Although a child may have many different
seizure types, may have a specific seizure type of concern to focus treatment.
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General characteristics seizures in Dravet syndrome 2. Seizures are treatment resistant
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Seizure ControlFewest seizures possible
No status epilepticus
MedicationsLimited adverse side
effects
Maximize Cognitive PotentialMaximize Quality of Life
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General characteristics seizures in Dravet Syndrome
3. Seizures prolonged especially when young
– Need specific acute seizure plan• Convulsive versus nonconvulsive status
epilepticus• May be different for seizure clusters
– Acute seizure Plan:• Home• Paramedics• Emergency room
– Revisions to plan over time
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General characteristics seizures in Dravet syndrome4. Specific seizure triggers (avoidance):• Vaccinations
– Do not recommend avoiding • Fever
– Antipyretics, benzodiazepines• Hyperthermia
– Use of cooling vest• Abrupt change in temperature• Excitement• Visual: Photic stimuli, visual patterns
– Sunglasses (Zeiss Z1F133)– Unilateral eye patching
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• De-Novo mutations of the sodium channel gene SCN1A in alleged vaccine encephalopathy: a retrospective study [Berkovic , Lancet 2006]
– 14 patients with alleged vaccine encephalopathy• SMEI: 8/8 patients + SCN1A mutations• SMEB: 3/4 patients + SCN1A mutations• Lennox-Gastaut: 0/2 patients + SCN1A mutations
• Effect of vaccination on onset and outcome of Dravet syndrome: a retrospective study [McIntosh, Lancet Neurology, 2010]
– 40 patients with DS: Vaccine proximate (n=12), vaccine distant (n=28)
– No difference in intellectual outcome, subsequent seizure type, or SCN1A mutation
– Early seizure onset in vaccine proximate group (7.8 weeks)
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Vaccinations in Dravet Syndrome
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Overview: History, Diagnosis, Seizure Evolution in Dravet Syndrome• Friday:
– Morning: SCN1A mutation, genetics– Afternoon: Treatment
• Saturday:– Track 1: Research• Clinical, SUDEP, Basic Science
– Track 2: Family Program
• Sunday: Co-morbidities– Cognitive, behavior, gait, sleep
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WELCOME!!
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Lurie Children’s Epilepsy Center