Abstract
Infantile spasms are a devastating epileptic encephalopathy of the young child. The continuing spasms and hypsarrhythmia have a deleterious effect on brain maturation and further cognitive development.
Corticotropin (adrenocorticotropic hormone) or corticosteroids have been the gold standard treatment for the last 40 years, but there is little agreement on the best agent to use, or the dosage and duration of the treatment. Despite this empirical approach, corticotropin or corticosteroids are effective in controlling spasms and normalising electroencephalograms in about 60% of cases. The major concern with this treatment is the occurrence of frequent and severe adverse effects.
The introduction of vigabatrin in the 1990s improved the outcome of infantile spasms. Vigabatrin shows an efficacy at least equal to that of corticosteroids, and even higher in specific groups such as those with tuberous sclerosis. The major advantages of vigabatrin are the ability to initiate treatment at the full dosage, rapid efficacy, suitability for outpatient treatment and particularly good tolerability with only minor adverse effects. Recently, however, the safety of vigabatrin has caused concern since a specific visual field loss has been reported in treated adults.
The current problem is determining the risk-benefit ratio of vigabatrin and corticosteroids/corticotropin in children with infantile spasms, and to specify the groups where their use could be optimal. Visual field loss is usually asymptomatic and can be detected only by perimetric visual field studies. In children, especially in the young or disabled, it is difficult if not impossible to detect the visual field loss and it is not yet known if children are at higher or lower risk for this adverse effect. Until a clear answer about the occurrence of this adverse effect in children has been established through randomised study, vigabatrin may still be considered first-line therapy in infantile spasms. Children who do not achieve a good response to vigabatrin should be switched to corticotropin/corticosteroid therapy.
Despite the efficacy of corticosteroids and vigabatrin, the use of the conventional antiepileptic drugs, the newly developed antiepileptic drugs and some promising results with ketogenic diet, 25 to 30% of patients with infantile spasms continue to have spasms and experience psychomotor regression. These drug-resistant patients could be candidates for surgery.
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References
Commission on the Classification and Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989; 30: 389–99
Hurst DL The epidemiology of infantile spasms. In: Dulac O, Chugani H, Dalla Bernardina B, editors. Infantile spasms and West syndrome. Philadelphia (PA): Saunders, 1994
Chugani HT, Shields WD, Shewmon DA, et al. Infantile spasms. I. PET identifies focal cortical dysgenesis in cryptogenic cases for surgical treatment. Ann Neurol 1990; 27: 406–13
Bachman D. Spontaneous remission of infantile spasms with hypsarrythmia [letter]. Arch Neurol 1981; 38: 785
Dulac O, Plouin P, Jambaqué I, et al. Spasmes infantiles épileptiques bénins. Rev EEG Neurophysiol Clin 1986; 16: 371–82
Sorel L, Dusaucy-Bauloye A. Apropos de 21 cas d’hypsarythmie de Gibbs, Son traitement spectaculaire par l’ACTH. Acta Neurol Belg 1958; 58: 130–41
Chiron C, Dulac O, Luna D, et al. Vigabatrin in infantile spasms [letter]. Lancet 1990; 335: 363–4
Chiron C, Dulac O, Beaumont D, et al. Therapeutic trial of vigabatrin in refractory infantile Spasms. J Child Neurol 1991; 6: S52–9
Lombroso CT. A prospective study of infantile spasms: clinical and therapeutic correlations. Epilepsia 1983; 24: 135–58
Glaze DG, Hrachovy RA, Forst JD, et al. Prospective study of outcome of infants with infantile spasms treated during controlled studies of ACTH and prednisone. J Pediatr 1988; 112: 389–96
Snead OC, Benton JW, Hosey LC, et al. Treatment of infantile spasms with high doses of ACTH: efficacy and plasma levels of ACTH and cortisol. Neurology 1989; 39: 1027–30
Baram TZ, Mitchell WG, Tournay A, et al. High dose corticotropin (ACTH) versus prednisone for infantile spasms: a prospective, randomised, blinded study. Pediatrics 1996; 97: 375–9
Willoughby JA, Thurston DL, Holowash J. Infantile myoclonic seizures: an evaluation of ACTH and corticosteroid therapy. J Pediatr 1966; 69: 1136–8
Hrachovy RA, Forst JD, Glaze DG. High dose, long duration versus low dose, short duration corticotropin therapy for infantile spasms. J Pediatr 1994; 124: 803–6
Riikonen R. Infantile spasms: modern practical aspects. Acta Pediatr Scand 1984; 73: 1–12
Singer WD, Rube EF, Haller JS. The effect of ACTH therapy upon infantile spasms. J Pediatr 1980; 96: 485–9
Hrachovy RA, Frost JD, Kellaway P, et al. Double blind study of ACTH vs prednisone therapy in infantile spasms. J Pediatr 1983; 103: 641–5
Snead OC, Benton JW, Myers GJ. ACTH and prednisone in childhood seizures disorders. Neurology 1983; 33: 966–70
Schlumberger E, Dulac O. A simple, effective and well tolerated regime for West syndrome. Dev Med Child Neurol 1994; 36: 863–72
Harris R. Some observations in children with infantile spasms treated with ACTH. Arch Dis Child 1964; 39: 546–70
Jeavons PM, Bower BD. Infantile spasms: a review of the literature and a study of 112 cases. London: Heinemen, 1964
Riikonen R, Donner M. ACTH therapy in infantile spasms: side effects. Arch Dis Child 1980; 55: 664–72
Okuno T, Ito M, Konishi Y, et al. Cerebral atrophy following ACTH therapy. J Comput Assist Tomogr 1980; 4: 20–3
Ito M, Takao T, Okunu T, et al. Sequential CT studies of24 children with infantile spasms on ACTH therapy. Dev Med Child Neurol 1983; 25: 475–80
Aicardi J. Epilepsy in children. New York (NY): Raven Press, 1986
Vidal C, Jordan W, Zieglgansberger W. Corticosterone reduces the excitability of hippocampal pyramidal cells in vitro. Brain Res 1986; 383(1-2): 54–9
Maeda H, Furune S, Nomura K, et al. Decrease of N-acetylaspartate after ACTH therapy in patients with infantile spasms. Neuropediatrics 1997; 28: 2622–267
Tekgul H, Tutuncuoglu S, Coker M, et al. Infantile spasms: the effect of corticotropin (ACTH) on the free amino acid profile in cerebrospinal fluid. Brain Dev 1999; 21(1): 20–3
Riikonen R, Soderstrom S, Vanhala R, et al. West syndrome: cerebrospinal fluid nerve growth factor and effect of ACTH. Pediatr Neurol 1997; 17: 224–9
Willing RP, Lagenstein I. Use of ACTH fragments in children with infantile spasms. Neuropediatrics 1982; 13: 55–8
Pavone L, Incorpora G, Larosa M, et al. Treatment of infantile spasms with sodium dipropylacetic acid. Dev Med Child Neurol 1981; 23: 454–61
Simon D, Penry JK. Sodium di-N-propylacetate in the treatment of epilepsy: a review. Epilepsia 1975; 16: 549–73
Bachman D. Use of valproic acid in the treatment of infantile spasms. Arch Neurol 1982; 39: 49–52
Siemes H, Spohr HL, Michael T, et al. Therapy of infantile spasm with valproate: results of a prospective study. Epilepsia 1988; 29: 553–60
Takuma Y, Seti T. Combination therapy of infantile spasms with high dose pyridoxal phosphate and low dose corticotropin. J Child Neurol 1996; 11: 35–40
Watanabe K. Medical treatment of West syndrome in Japan. J Child Neurol 1995; 10: 143–7
Dreifuss FE, Santilli N, Langer DH, et al. Valproic acid hepatic fatalities: a retrospective review. Neurology 1987; 37: 379–85
Bryant III AE, Dreifuss FE. Valproic acid hepatic fatalities. III: U.S. experience since 1986. Neurology 1996; 46: 465–9
Dulac O, Stern D, Rey E, et al. Sodium valproate monotherapy in childhood epilepsy. Brain Dev 1986; 8: 47–52
Lenn NJ, Ellis WG, Washburn ER, et al. Fatal hepatocerebral syndrome in siblings discordant for exposure to valproate. Epilepsia 1990; 24: 135–8
Harding BNP. Progressive neuronal degeneration of childhood with liver disease (Alpers-Huttenlocher syndrome): a personal review. J Child Neurol 1990; 5: 273–87
Oechsner M, Steen C, Sturenburg HJ, et al. Hyperammonaemic encephalopathy after initiation of valproate therapy in unrecognised ornithine transcarbamylase deficiency. J Neurol Neurosurg Psychiatry 1998 May; 64(5): 680–2
Davis R, Peters DH, McTavish D. Valproic acid. A reappraisal of its pharmacological properties and clinical efficacy in epilepsy. Drugs 1994 Feb; 47 (2): 332–72
Novak GP, Maytal J, Alshansky A, et al. Risk of excessive weight gain in epileptic children treated with valproate. J Child Neurol 1999 Aug; 14(8): 490–5.
Acharya S, Bussel JB. Hematologic toxicity of sodium valproate. J Pediatr Hematol Oncol 2000 Jan-Feb; 22(1): 62–5
Voltzke E, Doose H, Stephan E. The treatment of infantile spasms and hypsarrhythmias with Mogadon. Epilepsia 1967; 8: 64–70
Dreifuss S, Farwell J, Holmes G, et al. Infantile spasms, comparative trial of nitrazepam and corticotropin. Arch Neurol 1986; 43: 1107–10
Lim HC, Nigro MA, Beierwaltes P, et al. Nitrazepam-induced cricopharyngeal dysphagia, abnormal esophageal peristalsis and associated bronchospasm: probable cause of nitrazepam-related sudden death. Brain Dev 1992 Sep; 14(5): 309–14
Wyllie E, Wyllie R, Cruse RP, et al. The mechanism of nitrazepam-induced drooling and aspiration. N Engl J Med 1986 Jan 2; 314(1): 35–8
Pinder RM, Brogden RN, Speight TM, et al. Clonazepam: a review of its pharmacological properties and therapeutic efficacy in epilepsy. Drugs 1976 Nov; 12(5): 321–61
Rudolf M, Geddes DM, Turner JA, et al. Depression of central respiratory drive by nitrazepam. Thorax 1978 Feb; 33(1): 97–100
Rintahaka Pj, Nakagawa JA, Shewmon DA, et al. Incidence of death in patients with intractable epilepsy during nitrazepam treatment. Epilepsia 1999 Apr; 40(4): 492–6
Chung SH, Cox RA. Determination of pyridoxal phosphate levels in the brains of audiogenic and normal mice. Neurochem 1983; 8: 1245–59
Ito M, Mikawa H, Taniguchi T, et al. Cerebrospinal fluid GABA levels in children with infantile spasms. Neurology 1984; 34: 234–8
Ohtsuka Y, Matsuda M, Ogino T, et al. Treatment of the West syndrome with high-dose pyridoxal phosphate. Brain Dev 1997; 9: 418–21
Gram L, Klosterskov P, Dam M. Gamma-vinyl-GABA: a double-blind placebo-controlled trial in partial epilepsy. Ann Neurol 1985; 17: 262–6
Luna D, Dulac O, Beaumont D, et al. Vigabatrin in the treatment of childhood epilepsies: a single blind placebo controlled study. Epilepsia 1989; 30: 430–7
Lopez-Valdes E, Hernandez-Lain A, Simon R, et al. Treatment of refractory infantile epilepsy with vigabatrin in a series of 55 patients. Rev Neurol 1996; 24: 1255–7
Granstrom ML, Gaily E, Liukkonen E. Treatment of infantile spasms: results of a population based study with vigabatrin as the first drug for spasms. Epilepsia 1999; 40(7): 950–7
Koo B. Vigabatrin in the treatment of infantile spasms. Pediatr Neurol 1999; 20(2): 106–10
Aicardi J, Sabril IS, Mumford J, et al. Vigabatrin as initial therapy for infantile spasms: an European retrospective survey. Epilepsia 1996; 37: 638–42
Vigevano F, Cilio MR. Vigabatrin versus ACTH as first line treatment for infantile spasms: a randomized, prospective study. Epilepsia 1997; 38: 1270–4
Chiron C, Dumas C, Jambaqué I, et al. Randomized trial comparing vigabatrin and hydrocortisone in infantile spasms due to tuberous sclerosis. Epilepsy Res 1997; 26: 389–95
Cossette P, Riviello JJ, Carmant L, et al. ACTH versus vigabatrin therapy in infantile spasms: a retrospective study. Neurology 1999; 52: 1691–4
Appleton RE, Peters ACB, Mumford JP, et al. Randomized, placebo-controlled study of vigabatrin as first line treatment of infantile spasms: vigabatrin as first line monotherapy in newly diagnosed infantile spasms. Epilepsia 1999; 40(11): 1627–33
Eke T, Talbot JF, Lawden MC. Severe persistent visual field constriction associated with vigabatrin [letter]. BMJ 1997; 314: 180–1
Mackenzie R, Klistomer A. Severe persistent visual field constriction associated with vigabatrin [letter]. BMJ 1997; 314: 1693
Wilson OA, Brodie MJ. Severe persistent visual field constriction associated with vigabatrin [letter]. BMJ 1997; 314: 1693
Wong IC, Mawer GE, Sander JWAS. Severe persistent visual field constriction associated with vigabatrin. Reaction may be dose dependent [letter]. BMJ 1997; 314: 1693–4
Blackwell N, Hayllar J, Kelly G. Severe persistent visual field constriction associated with vigabatrin [letter]. BMJ 1997; 314: 1694
Harding JFA. Severe persistent visual field constriction associated with vigabatrin [letter]. BMJ 1997; 314: 1694
Krauss GL, Johnson MA, Miller NR. Vigabatrin associated retinal cone system dysfunction. Neurology 1998; 50: 614–8
Harding JFA, Wild JM, Robertson K, et al. Electroculography, ERG’s, multifocal ERG’s and VEPs in epileptic patients showing visual field disorder. Electroencephalogr Clin Electrophysiol 1997; 103: 96
Ruether K, Pung T, Kellner U, et al. Electrophysiologic evaluation of a patient with peripheral visual field constriction associated with vigabatrin. Arch Ophtalmol 1998; 116: 817–9
Kalvinainen R, Nousiainen I, Mantyjarvi M, et al. Vigabatrin, a GABAergic antiepileptic drug, causes concentric visual field defects. Neurology 1999; 53: 922–6
Wild CM, Martinez C, Reinshagen G, et al. Characteristics of a unique visual field defect attributed to vigabatrin. Epilepsia 1999; 40(12): 1784–94
Butler WH, Ford GP, Newberne GW. A study of the effect of vigabatrin on the central nervous system and retina of Sprague-Dawley and Lister-Hooded rats. Toxicol Pathol 1987; 15: 143–8
Gibson JP, Yarrington JT, Loudy DE, et al. Chronic toxicity studies with vigabatrin, a GABA transaminase inhibitor. Toxicol Pathol 1990; 18: 225–38
Mauguiere F, Chauvel P, Dewailly J, et al. No effect of long term vigabatrin on central nervous system in patients with refractory epilepsy: results of a multicenter study of somatosensory and visual evoked potentials. Epilepsia 1997; 38: 301–8
Riekkinen P, Aikia M, Partanen K. Efficacy and safety of vigabatrin monotherapy. Epilepsia 1997; 38Suppl.: 104
Cannon DJ, Buttler WH, Mumford JP, et al. Neuropathological findings in patients receiving long term vigabatrin therapy for chronic intractable epilepsy. J Child Neurol 1991; 6: 17–24
Gross-Tsur V, Banin E, Shahar E, et al. Visual impairment in children with epilepsy treated with vigabatrin. Ann Neurol 2000 Jul; 48(1): 60–4
Ianetti P, Spalice A, Perla FM, et al. Visual field constriction in children with epilepsy on vigabatrin treatment. Pediatrics 2000 Oct; 106(4): 838–42
Wohlrab G, Boltshauser E, Schmitt B, et al. Visual field constriction is not limited to children treated with vigabatrin. Neuropediatrics 1999 Jun; 30(3): 130–2
Versino M, Veggiotti P. Reversibility ofvigabratin-induced visual- field defect. Lancet 1999 Aug 7; 354(9177): 486
Appleton RE. Guideline may help in prescribing vigabatrin. BMJ 1998; 317: 1322
Guideline for prescribing vigabatrin in children has been revised. Vigabatrin Paediatric Advisory Group. BMJ 2000 May 20; 320 (7246): 1404–5
Vigabatrin Paediatric Advisory Group. Advisory group reply. In: Lux AL, Edwards SW, Osborne JP, et al. Revised guideline for prescribing vigabatrin in children: guideline’s claim about infantile spasms is not based on appropriate evidence. BMJ 2001 Jan 27; 322 (7280): 236–7
Lux AL, Edwards SW, Osborne JP, et al. Revised guideline for prescribing vigabatrin in children: guideline’s claim about infantile spasms is not based on appropriate evidence. BMJ 2001 Jan 27; 322(7280): 236–7
Riikonen RS. Steroids or vigabatrin in the treatment of infantile spasms? Pediatr Neurol 2000 Nov; 23(5): 403–8
Dulac O. Vigabatrin-optimal use in children. In: Vigabatrin: current status and future prospects. 23rd International Epilepsy Congress; 1999 Sep 12-17: Prague. TMG Healthcare Communications: Prague, 1999
Prasad AN, Penney S, Buckley DJ. The role of vigabatrin in childhood seizure disorders: results from a clinical audit. Epilepsia 2001; 42(1): 54–61
Langtry HD, Wagstaff AJ. Management of epilepsy: defining the role of lamotrigine. Dis Manage Health Outcomes 1997; 1: 254–70
Veggiotti P, Cieuta C, Rey E, et al. Lamotrigine in infantile spasms [letter]. Lancet 1994; 44: 1375–6
Sclumberger E, Chavez F, Palacios L, et al. Lamotrigine in treatment of 120 children with epilepsy. Epilepsia 1994; 35: 359–67
Rosenfeld WE, Sachdeo RC, Faught RE, et al. Long term experience with topiramate as adjunctive therapy in patients with partial onset seizures: retrospective survey of open label treatment. Epilepsia 1998; 38Suppl. 1 (1): 34–6
Sachdeo RC, Reife RA, Lim P, et al. Topiramate monotherapy for partial onset seizures. Epilepsia 1997; 38: 294–300
Glauser TA, Sachdeo RC, Ritter FJ, et al. Topiramate in Lennox-Gastaut syndrome: a double blind trial. Neurology 1997; 48: 1729
Glauser TA, Clark PO, Strawsburg R. A pilot study of topiramate in the treatment of infantile spasms. Epilepsia 1998; 39(12): 1324–8
Glauser TA, Clark PO, McGee K. Long term response to Topiramate in patients with West syndrome. Epilepsia 2000; 41(1): 91–4
Yanai S, Hanai T, Narazaki O. Treatment of infantile spasms with zonisamide. Brain Dev 1999; 21(3): 157–61
Kawawaki H, Tomiwa K, Shiraishi K, et al. Efficacy of zonisamide in West syndrome [abstract]. No To Hattatsu 1999; 31(3): 263–7
Suzuki Y, Nagai T, Ono J. Zonizamide monotherapy in newly diagnosed infantile spasms. Epilepsia 1997; 38: 1035–8
Kishi T, Nejihashi Y, Kajiyama M, et al. Successful zonisamide for infants with hypsarrhythmia. Pediatr Neurol 2000; 23(3): 274–7
Pennel PB, Ogaily MS, Macdonald RL. A plastic anemia in a patient receiving felbamate for complex partial seizure. Neurology 1995; 45: 456–60
Hurst DL, Rolan TD. The use of felbamate to treat infantile spasms. J Child Neurol 1995; 10: 134–44
Coppola G, Pascotto A. Felbamate in refractory infantile spasms. Epilepsia 1997; 38Suppl.: 37
Monaghan EP, Navalta LA, Shum L, et al. Initial human experience with ganaxolone, a neuroactive steroid with antiepileptic activity. Epilepsia 1997; 38(9): 1026–31
Gasior M, Ungard JT, Beekman M, et al. Acute and chronic effect of the synthetic neuroactive steroid, ganaxolone, against the convulsive and lethal effects of pentylenetetrazol in seizure-kindled mice: comparison with diazepam and valproate. Neuropharmacology 2000; 39(7): 1184–96
Kerrigan JF, Shields WD, Nelson TY, et al. Ganoxolone for treating infantile spasms: a multicenter, open-label, add-on trial. Epilepsy Res 2000; 42(2-3): 133–9
Swink T, Vining EP, Casey JC, et al. Efficacy of the ketogenic diet in children under 2 years of age. Epilepsia 1997; 38Suppl.: 26
Freeman JM, Vining EP. Ketogenic diet: a time tested, effective, and safe method for treatment of intractable childhood epilepsy. Epilepsia 1998; 39: 450–7
Vining EP. Clinical efficacy of the ketogenic diet. Epilepsy Res 1999; 37(3): 181–90
Hassan AM, Keene DL, Whiting SE, et al. Ketogenic diet in the treatment of refractory epilepsy in childhood. Pediatr Neurol 1999; 21(2): 548–52
Vining EP, Freeman JM, Ballaban-Gil K, et al. A multicenter study of the efficacy of the ketogenic diet. Arch Neurol 1998; 55(11): 1433–7
Ballaban-Gil K, Callahan C, O’Dell C, et al. Complications of the ketogenic diet. Epilepsia 1998; 39(7): 744–8
Pechadre JC, Sauvezic B, Osier C, et al. Traitement des encéphalopathies épileptiques des enfants par les immunoglobulines. Rev EEG Neurophysiol Clin 1977; 7: 443–7
Ariizumi M, Baba K, Shiihara H, et al. High dose gammaglobulin for intractable childhood epilepsy. Lancet 1983; II: 162–3
Ariizumi M, Baba K, Hibio S, et al. Immunoglobulin therapy in West syndrome. Brain Dev 1987; 9: 422–5
Echenne B, Dulac O, Parayre-Chanez MJ, et al. Treatment of infantile spasms with intravenous gammaglobulines. Brain Dev 1991; 13: 313–9
Chugani TH, Shewmon AD, Shields DW, et al. Surgery for intractable infantile spasms: neuroimaging perspectives. Epilepsia 1993; 34(4): 764–71
Asarnow RF, LoPresti C, Guthrie D, et al. Developmental outcomes in children receiving resection surgery for medically intractable infantile spasms. Dev Med Child Neurol 1997; 39(7): 430–40
Chugani HT, Conti JR. Etiologic classification of infantile spasms in 140 cases: role of positron emission tomography. J Child Neurol 1996; 11(1): 44–8
Kramer U, Sue WC, Mikati MA. Focal features in West syndrome indicating candidacy for surgery. Pediatr Neurol 1997; 16(3): 213–7
Pinard JM, Delalande O, Chiron C, et al. Callosotomy for epilepsy after West syndrome. Epilepsia 1999; 40(12): 1727–34
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The author wishes to thank Dr Catherine Chiron and Professor Olivier Dulac for their advice.
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Nabbout, R. A Risk-Benefit Assessment of Treatments for Infantile Spasms. Drug-Safety 24, 813–828 (2001). https://doi.org/10.2165/00002018-200124110-00003
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DOI: https://doi.org/10.2165/00002018-200124110-00003