Surgical treatment for drug-resistant epilepsy due to early brain injury in children.

BACKGROUND: The study aimed to summarize the indications and clinical features of pediatric drug-resistant epilepsy associated with early brain injury, surgical outcomes, and prognostic factors. METHODS: We retrospectively analyzed children diagnosed with drug-resistant epilepsy due to early brain injury, who had undergone surgery at the Pediatric Epilepsy Center of Peking University First Hospital from May 2014 to May 2021. Clinical data of vasculogenic and non-vasculogenic injuries from early brain damage were compared and analyzed. The surgical outcomes were assessed using the Engel grading system. RESULTS: The median ages at acquiring injury, seizure onset, and surgery among 65 children were 19.0 (0-120) days, 8.6 (0-136.5) months, and 62.9 (13.5-234) months, respectively. Of the 14 children with non-vasculogenic injuries, 12 had posterior ulegyria. Unilateral or bilateral synchronous interictal epileptiform discharges were located mainly in the posterior quadrant in 10 children (71 %), and unilateral posterior quadrant or non-lateralized ictal region in eight children (57 %). The surgical approach was mainly temporo-parieto-occipital or parieto-occipital disconnection in nine children. Of 49 children with vasculogenic injuries, magnetic resonance imaging revealed hemispheric abnormalities in 38. Unilaterally hemispheric or bilateral interictal epileptiform discharges were observed in 36 children (73 %), whereas 42 (86 %) had unilateral hemispheric or non-lateralized ictal onset. The surgical procedure involved hemispherotomy in 38 children (78 %) and lobectomy or disconnection, multilobectomy or disconnection and hemispherotomy in 5, 20, and 40 children, respectively. Fifty-five patients (84.6 %) achieved remission from seizure during follow-up at 5.4 years. Age at surgery (odds ratio = 1.022, 95 % confidence interval = 1.003-1.042, P = 0.023) and etiology (odds ratio = 17.25, 95 % confidence interval = 2.778-107.108, P = 0.002) affected the seizure outcomes. CONCLUSION: Children with drug-resistant epilepsy due to early brain injury can successfully be treated with surgery after rigorous preoperative screening. Good surgical outcomes are associated with an early age at surgery and an etiology of vasculogenic injury.

Innovative insight into the mechanism of enantioselective skin permeation for chiral drugs.

OBJECTIVES: A profound comprehension of the molecular mechanisms underpinning the enantioselective transdermal permeation of chiral drugs is critical in the design and assessment of transdermal preparations. The primary objective of this study is to investigate the distinct skin permeation behaviors exhibited by enantiomers of non-steroidal anti-inflammatory drugs (NSAIDs) and elucidate the intricate molecular mechanism at play. METHODS: In vitro and in vivo transdermal permeation studies of chiral NSAIDs were performed using transdermal patch and solution system. Chiral interaction between NSAIDs enantiomers and synthesized chiral ceramide present in the skin was characterized to clarify the different transdermal behaviors. RESULTS: The S-enantiomers of NSAIDs exhibited higher permeability through the skin than R-enantiomer in vitro (1.5-fold) and in vivo (2.0-fold), which was attributed to a stronger interaction between S-enantiomer and ceramide caused by more favorable spatial conformations. S-enantiomer required lower activation energy (24.4 kJ/mol) and Gibbs energy (43.3 kJ/mol), which was favorable in forming the H-bond with ceramide in the skin, resulting in more permeation. CONCLUSION: This research furnished an innovative comprehension of the molecular underpinnings governing the enantioselective permeation of drug enantiomers through the skin, fostering the minimization of undesired enantiomer ingestion (distomers) and amplifying therapeutic efficiency.

The enantioselective enhancing effect and mechanistic insights of chiral enhancers in transdermal drug delivery.

Overlook of chiral consideration in transdermal drug delivery increases administrated dose and risk of side effects, decreasing therapeutical effects. To improve the transdermal delivery efficiency of eutomer, this work focused on investigating the law and mechanism of enantioselective enhancing effects of chiral permeation enhancers on drug enantiomers. Chiral nonsteroidal anti-inflammatory drugs and terpene permeation enhancers were selected as model drug and enhancers. The results indicated that the L-isomer of permeation enhancers increased the skin absorption of S-enantiomer of drug and D-isomer improve the permeation of R-enantiomer, in which the enhancement effect (ER) of L-menthol on S-enantiomer (ER = 3.23) was higher than that on R-enantiomer (ER = 1.49). According to the pharmacokinetics results, L-menthol tended to enhance the permeation of S-enantiomer better than R-enantiomer (2.56 fold), and showed excellent in vitro/in vivo correlations. The mechanism study showed that L-isomer of permeation enhancers improved the permeation of S-enantiomer by increasing the retention, but the D-isomer by improving partition for better permeation. Enantioselective mechanism indicated that the weaker chiral H-bond interaction between drug-chiral enhancers was caused by the enantiomeric conformation. Additionally, stronger chiral enhancers-skin interaction between L-isomer and S-conformation of ceramide produced better enhancing effects. In conclusion, enantioselective interaction of chiral drug-chiral enhancers and chiral enhancers-chiral skin played a critical role in transdermal drug delivery, rational utilization of which contributed to improving the uptake of eutomer and inhibiting distomers to decrease a half of dose and side effects, increasing transdermal therapeutical efficiency.

Pediatric epilepsy surgery in patients with Lennox-Gastaut syndrome after viral encephalitis.

Objective: To analyse the surgical outcomes of pediatric patients with Lennox-Gastaut syndrome (LGS) secondary to viral encephalitis. Methods: We retrospectively analyzed the data of four patients with LGS secondary to viral encephalitis who underwent surgery at the pediatric epilepsy center of Peking University First Hospital from January 2014 to December 2019. Preoperative evaluations included a detailed history, long-term video electroencephalography (VEEG), brain magnetic resonance imaging (MRI), positron emission tomography (PET) and a neuropsychological test. All patients were followed up at 1, 3, and 6 months and then yearly. The surgical outcome was evaluated according to the Engel classification. Results: Among the four children, the surgeries were right temporo-parieto-occipital disconnection (case 1), corpus callosotomy (case 2), left temporo-parieto-occipital disconnection (case 3), and left temporal lobectomy (case 4). The pathology was gliosis secondary to viral encephalitis. The median follow-up time was 4 years (3-5 years). At the last follow-up, one case had Engel I, two cases had Engel III, and one case had Engel IV. Conclusions: Preliminary observations shows that surgical treatment may be challenging for patients with LGS secondary to viral encephalitis. However, suitable surgical candidacy and approaches have a significant impact on the prognosis of the patients.

Safety and efficacy of rapid withdrawal of antiseizure medications during long-term video-electroencephalogram monitoring in children with drug-resistant epilepsy: A retrospective study.

OBJECTIVE: Performing long-term video-electroencephalographic monitoring (LTVEM) to obtain the ictal electroencephalogram (EEG) is important for presurgical evaluation. This study aimed at investigating the safety and efficacy of our protocol developed at Peking University First Hospital (PUFH) for rapid withdrawal of antiseizure medications (ASMs) during LTVEM to induce seizures in children with drug-resistant epilepsy (DRE) exhibiting nondaily seizures. METHODS: Children with DRE who followed the PUFH protocol for rapid withdrawal of ASMs during LTVEM between 2018 and 2021 were enrolled. The occurrence of seizures, number of ASMs withdrawn, seizure onset time after ASM tapering initiation, changes in interictal epileptiform discharge (IED), and adverse events were evaluated during LTVEM. RESULTS: Among 80 children evaluated in this study, seizures were induced successfully in 72 (90%) children. Furthermore, no change in IED sites was observed in these 72 children following the initiation of ASM tapering while 2 children exhibited secondary bilateral tonic-clonic seizures. The median time from ASM tapering initiation to the onset of the first seizure was found to be 3 days (2-4), while the median number of ASMs withdrawn was 2 (1-2). Finally, 66 children (91.7%) had habitual seizures while 6 children had nonhabitual seizure semiology. SIGNIFICANCE: The PUFH protocol can be used for the rapid withdrawal of ASMs during LTVEM in children with DRE. Using this protocol, ictal EEG patterns can be obtained in a relatively short time for most patients with fewer adverse effects during LTVEM, which may provide meaningful electro-clinical information for presurgical evaluation.

An Explainable Statistical Method for Seizure Prediction Using Brain Functional Connectivity from EEG.

Background: Epilepsy is a group of chronic neurological disorders characterized by recurrent and abrupt seizures. The accurate prediction of seizures can reduce the burdens of this disorder. Now, existing studies use brain network features to classify patients' preictal or interictal states, enabling seizure prediction. However, most predicting methods are based on deep learning techniques, which have weak interpretability and high computational complexity. To address these issues, in this study, we proposed a novel two-stage statistical method that is interpretable and easy to compute. Methods: We used two datasets to evaluate the performance of the proposed method, including the well-known public dataset CHB-MIT. In the first stage, we estimated the dynamic brain functional connectivity network for each epoch. Then, in the second stage, we used the derived network predictor for seizure prediction. Results: We illustrated the results of our method in seizure prediction in two datasets separately. For the FH-PKU dataset, our approach achieved an AUC value of 0.963, a prediction sensitivity of 93.1%, and a false discovery rate of 7.7%. For the CHB-MIT dataset, our approach achieved an AUC value of 0.940, a prediction sensitivity of 93.0%, and a false discovery rate of 11.1%, outperforming existing state-of-the-art methods. Significance. This study proposed an explainable statistical method, which can estimate the brain network using the scalp EEG method and use the net-work predictor to predict epileptic seizures. Availability and Implementation. R Source code is available at https://github.com/HaoChen1994/Seizure-Prediction.

Optimization design of sialic acid derivatives enhances the performance of liposomes for modulating immunosuppressive tumor microenvironments.

AIMS: Sialic acid derivatives (SA-derivatives) provide a nanomedicine platform for tumor-targeted delivery and treatment, and allow modulation of immunosuppressive tumor microenvironments with excellent therapeutic effects. Further, the multi-reactive groups of sialic acid (SA) contribute to the diversity of SA derivatives, which inevitably has implications for drug delivery systems and tumor therapy. However, relevant research remains lacking at present. Therefore, this study aimed to explore the effects of SA derivatives on SA-mediated drug delivery systems. MAIN METHODS: Four SA-derivatives with different linking bonds (ester and amide bonds), different linking groups (hydroxyl and carboxyl), and different linking objects (cholesterol, octadecanoic acid, and octadecylamine) were synthesized and the respective SA derivative-modified doxorubicin liposomes were prepared. In-depth research was conducted using both cells and animals. KEY FINDINGS: We found that an SA-cholesterol conjugate (SA-CH; linking bond, amide bond; linking group, carboxyl; linking object, cholesterol) could improve liposome stability, reduce liposome adsorption to plasma proteins, and enhance the targeting of liposomes for killing tumor-associated macrophages (TAMs). Reduced TAMs in the immunosuppressive tumor microenvironment lead to enhanced tumor infiltration of CD8+ T cells. SIGNIFICANCE: The results of this experiment provide clarity for research and development on SA-derivatives and a theoretical basis for clinical trials of SA-derivative-modified nanoparticles.

Lesional Intractable Epileptic Spasms in Children: Electroclinical Localization and Postoperative Outcomes.

To analyze the influence of seizure semiology, electroencephalography (EEG) features and magnetic resonance imaging (MRI) change on epileptogenic zone localization and surgical prognosis in children with epileptic spasm (ES) were assessed. Data from 127 patients with medically intractable epilepsy with ES who underwent surgical treatment were retrospectively analyzed. ES semiology was classified as non-lateralized, bilateral asymmetric, and focal. Interictal epileptiform discharges were divided into diffusive or multifocal, unilateral, and focal. MRI results showed visible local lesions for all patients, while the anatomo-electrical-clinical value of localization of the epileptogenic zone was dependent on the surgical outcome. During preoperative video EEG monitoring, among all 127 cases, 53 cases (41.7%) had ES only, 46 (36.2%) had ES and focal seizures, 17 (13.4%) had ES and generalized seizures, and 11 (8.7%) had ES with focal and generalized seizures. Notably, 35 (27.6%) and 92 cases (72.4%) showed simple and complex ES, respectively. Interictal EEG showed that 22 cases (17.3%) had bilateral multifocal discharges or hypsarrhythmia, 25 (19.7%) had unilateral dominant discharges, and 80 (63.0%) had definite focal or regional discharges. Ictal discharges were generalized/bilateral in 71 cases (55.9%) and definite/lateralized in 56 cases (44.1%). Surgically resected lesions were in the hemisphere (28.3%), frontal lobe (24.4%), temporal lobe (16.5%), temporo-parieto-occipital region (14.2%), and posterior cortex region (8.7%). Seizure-free rates at 1 and 4 years postoperatively were 81.8 and 72.7%, respectively. There was no significant difference between electroclinical characteristics of ES and seizure-free rate. Surgical treatment showed good outcomes in most patients in this cohort. Semiology and ictal EEG change of ES had no effect on localization, while focal or lateralized epileptiform discharges of interictal EEG may affect lateralization and localization. Complete resection of epileptogenic lesions identified via MRI was the only factor associated with a positive surgical outcome.

Subtotal hemispherotomy for intractable lesional hemispheric epilepsy without hemiparesis in children.

PURPOSE: We analyzed the surgical indications, outcomes, and prognostic factors of subtotal hemispherotomy for intractable lesional hemispheric epilepsy in children with almost normal motor function and summarized its surgical strategies. METHODS: We retrospectively analyzed 20 children who underwent subtotal hemispherotomy (hemispheric disconnection sparing sensorimotor cortex) between March 2015 and May 2021. The children were divided into seizure-free group and residual seizures group according to their surgical outcomes. The surgical outcome was based on International League Against Epilepsy (ILAE) classification (class 1-6). All presurgical evaluation data were collected and analyzed. RESULTS: Among the 20 children, the mean age at the time of seizure onset, mean age at the time of surgery, and mean follow-up time was 3.2 ± 2.8, 7.5 ± 4.4, and 3.5 ± 2.1 years, respectively. All children had hemispheric lesion on MRI. At the last follow-up evaluation, 75% (15/20) of children remained seizure-free. Univariate analyses revealed that the electrocorticogram finding of epileptiform discharges in the central cortex after disconnection were poor prognostic factors for seizure outcomes (P < 0.05). Disconnection of the central operculum and insula was a poor prognostic factor for motor function after surgery (P < 0.05). CONCLUSIONS: For intractable lesional hemispheric epilepsy with no hemiparesis, subtotal hemispherotomy can be performed with favorable seizure outcome. Disconnection of the central operculum and insula may increase the possibility of motor function injury.

A prediction model integrating synchronization biomarkers and clinical features to identify responders to vagus nerve stimulation among pediatric patients with drug-resistant epilepsy.

AIMS: Vagus nerve stimulation (VNS) is a neuromodulation therapy for children with drug-resistant epilepsy (DRE). The efficacy of VNS is heterogeneous. A prediction model is needed to predict the efficacy before implantation. METHODS: We collected data from children with DRE who underwent VNS implantation and received regular programming for at least 1 year. Preoperative clinical information and scalp video electroencephalography (EEG) were available in 88 children. Synchronization features, including phase lag index (PLI), weighted phase lag index (wPLI), and phase-locking value (PLV), were compared between responders and non-responders. We further adapted a support vector machine (SVM) classifier selected from 25 clinical and 18 synchronization features to build a prediction model for efficacy in a discovery cohort (n = 70) and was tested in an independent validation cohort (n = 18). RESULTS: In the discovery cohort, the average interictal awake PLI in the high beta band was significantly higher in responders than non-responders (p < 0.05). The SVM classifier generated from integrating both clinical and synchronization features had the best prediction efficacy, demonstrating an accuracy of 75.7%, precision of 80.8% and area under the receiver operating characteristic (AUC) of 0.766 on 10-fold cross-validation. In the validation cohort, the prediction model demonstrated an accuracy of 61.1%. CONCLUSION: This study established the first prediction model integrating clinical and baseline synchronization features for preoperative VNS responder screening among children with DRE. With further optimization of the model, we hope to provide an effective and convenient method for identifying responders before VNS implantation.

Postoperative seizure and developmental outcomes of children with hemimegalencephaly and drug-resistant epilepsy.

OBJECTIVE: To evaluate seizure and developmental outcomes in the short and long term in children with hemimegalencephaly (HMEG) after surgery. METHODS: This is a cohort study of 36 children who underwent surgery for HMEG were followed up for at least 1 year postoperatively. The Griffiths Mental Development Scales, Ages and Stages Questionnaire version 3, and Peabody Developmental Motor Scales were used to assess development. RESULTS: The median postoperative follow-up duration was 2.7 (1.0-5.0) years, and median age at surgery was 1.9 years (5.8 months-5.9 years). At the last follow-up, 83% of children were seizure-free. the predicted probability of being seizure-free three years after surgery was 79%. The proportion of patients who were moderate to severe delay declined from 97% preoperatively to 76% at least 1 year after surgery. Catch-up, stabilization, and regression of developmental quotient (DQ) was observed in 41%, 35%, and 24% of children 3 months after surgery, respectively. The corresponding proportions during long-term follow-up were 40%, 33%, and 27%, respectively. Change of DQ shortly after surgery was negatively correlated with age at seizure onset and age at surgery. The long-term DQ was positively correlated with the preoperative DQ. Long-term change of DQ was positively correlated with change of DQ shortly after surgery. CONCLUSIONS: Most of patients with HMEG could achieve seizure free after surgery. After surgery, the proportion of catch-up, stabilization, and regression in both short- and long-term DQ was approximately 40%, 35%, and 25%, respectively. The change of DQ shortly after surgery may be a predictor for long-term developmental change.

Surgical treatment of children with drug-resistant epilepsy involving the Rolandic area.

We retrospectively analysed the clinical features and prognostic factors of surgery in children with drug-resistant epilepsy involving the Rolandic area, and the relationship between the stable compound muscle action potentials (CMAPs) of intraoperative neurophysiological monitoring (IONM) and good motor function outcomes postoperatively. A study was conducted on the clinical data of 91 patients with epilepsy who underwent epilepsy surgery involving the Rolandic area and IONM from November 2015 to February 2019. In total, 91 patients were included in this study. The median age at seizure onset was 1.3 years old. The median age at surgery was 4.4 years old. Twenty-seven patients (29.7%), with age at onset below three years old, had epileptic spasms. The central operculum was the most common surgical region in 52 patients (57.1%). The most common pathology was focal cortical dysplasia (FCD) in 67 patients. At the last follow-up visit, 69 patients (75.8%) were seizure-free. Interictal epileptiform discharges in the Rolandic area were associated with good seizure outcome (p=0.016). Out of 91 patients, successful IONM was performed in 88 patients (96.7%). Stable CMAP was seen in 79 of 88 patients (89.8%), and irreversible disappearance of CMAP was seen in nine patients (10.2%). New permanent motor deficit was observed in 13 of 88 patients (14.8%). There was a significant correlation between stable CMAP and good motor function outcome (p<0.001). This is the largest reported cohort of children with drug-resistant epilepsy involving the Rolandic area who received surgery from a single centre. Epileptic spasms were only observed in young children with age at onset below three years old. The major aetiology was FCD. The rate of seizure freedom was 75.8%. Epileptiform discharges in the Rolandic area were the main prognostic factor affecting surgical outcome. Stable CMAP can predict good motor function outcome postoperatively.

Seizure Outcome and Its Prognostic Predictors After Hemispherotomy in Children With Refractory Epilepsy in a Chinese Pediatric Epileptic Center.

Object: To explore the post-hemispherotomy seizure outcome and its prognostic predictors in children with refractory epilepsy. Methods: We reviewed 83 consecutive child patients with refractory epilepsy who underwent a hemispherectomy from June 2014 to January 2017 at our Pediatric Epilepsy Center. Demographic, clinical, EEG, neuroimaging, and surgical data were collected. Seizure outcome data were collected via outpatient clinics as well as telephone visits and were graded according to Engel criteria. Logistic regression model and Cox proportional hazard regression model were, respectively, applied to explore the related factors predicting the seizure outcomes of children after a hemispherotomy. Results: Of the 83 patients, 55 (63.2%) were male. The mean seizure onset age was 1.9 years (0-8.7 years), and the mean surgery age was 5 years (0.8-14 years). At a mean follow-up of 3 years, 69 children (83.1%) were seizure free, and 14 (16.9%) exhibited seizure recurrence. In a univariate analysis, whether or not considering follow-up time, a non-lateralized interictal EEG pattern, bilateral PET abnormalities and acute postoperative seizures (APOS) could all predict poor seizure outcomes post-hemispherotomy. Bilateral PET abnormalities were independently correlated with unfavorable seizure outcomes in the multivariate Logistic regression analysis (Odds ratio(OR) = 13.05, 95%CI = 1.52-112.29, P = 0.019) and in the multivariate Cox proportional hazard analysis(OR = 13.99, 95%CI = 2.75-71.17, P = 0.001). Conclusions: Child epileptic patients with bilateral PET abnormalities may have poor seizure outcomes after a hemispherotomy procedure. This study will facilitate better candidate selection for hemispherotomies and early identification of unfavorable seizure outcomes.

Generalized seizures presurgically in a cohort of children with hemispherectomy: Predictors and a potential link to surgical outcome?

PURPOSE: Generalized seizures were often thought to be contraindications for hemispherectomy. However, few studies had investigated this issue comprehensively, as well as the predictors for generalized seizures in hemispheric lesion. We studied the predictors of generalized seizures and their potential link to seizure outcomes in a cohort of children who underwent hemispherectomy. METHODS: A cohort of 76 children with hemispherectomy were reviewed and dichotomized into two groups with and without generalized seizures confirmed by vEEG presurgically. All preoperative evaluation data correlated to generalized seizures and postoperative prognosis were collected and analysed. RESULTS: Of 76 patients, 11 (14.5%) cases were documented with various generalized seizures, including atypical absence (54.5%, 6/11), myoclonic (45.5%, 5/11), atonic (36.4%, 4/11), myoclonic-atonic (18.2%, 2/11), myoclonic-absence (9.1%, 1/11) and spasms (9.1%). Electrical status epilepticus during sleep (ESES) was recorded in 3 patients (27.3%, 3/11). At last follow-up, 72.7% (8/11) patients remained seizure-free. ESES was a predictor of generalized seizures (χ2 = 4.69, P = 0.043). No correlation was found between generalized seizures and unfavourable postoperative seizure outcome (P = 0.153). For different seizure types, focal to bilateral tonic-clonic seizures (P = 0.020) and myoclonic-atonic seizures (P = 0.002) might correlate with unfavourable outcomes. CONCLUSION: Generalized seizures were not an absolute contraindication for hemispherectomy. Those patients with ESES might experience generalized seizures presurgically. Focal to bilateral tonic-clonic seizures and myoclonic-atonic seizures pre-surgery may indicate unfavourable post-operative seizure outcomes.

Antioxidant properties and neuroprotective effects of isocampneoside II on hydrogen peroxide-induced oxidative injury in PC12 cells.

Oxidative stress has been considered as a major cause of cell damage in various neurodegenerative disorders. One of the reasonable strategies for delaying the disease's progression is to prevent reactive oxygen species (ROS) mediated cellular injury by dietary or pharmaceutical augmentation of free radical scavengers. Isocampneoside II (ICD) is an active phenylethanoid glycoside isolated from the medicinal hardwood genus Paulownia. This study was designed to explore free radical scavenging potential of ICD in different in vitro systems and its protective role in hydrogen peroxide (H2O2)-induced oxidative stress and apoptotic death in cultured rat pheochromocytoma (PC12) cells. The results showed ICD eliminated approximately 80.75% superoxide radical at the concentration of 0.1mg/ml and inhibited metal chelating by 22.07% at 8 mg/ml. Additionally, ICD showed a strong ability on reducing power and provided protection against oxidative protein damage induced by hydroxyl radicals. Pretreatment of PC12 cells with ICD prior to H2O2 exposure elevated cell viability, enhanced activity of superoxide dismutase and catalase, and decreased levels of malondialdehyde and intracellular ROS. Furthermore, ICD inhibited cell apoptosis and Bax/Bcl-2 ratio induced by H2O2. These findings suggested ICD may be considered as a potential antioxidant agent and should encourage for further research in neurodegenerative diseases.