|Classification and external resources|
|Patient UK||Lennox–Gastaut syndrome|
Lennox–Gastaut syndrome (LGS) is a difficult-to-treat form of childhood-onset epilepsy that most often appears between the second and sixth year of life. LGS is characterized by a triad of signs including frequent seizures of multiple types, an abnormal EEG pattern of less than 2.5 Hz slow spike wave activity, and moderate to severe intellectual impairment.
- 1 Characteristics
- 2 Causes
- 3 Diagnosis
- 4 Treatment
- 5 Prognosis
- 6 Incidence and prevalence
- 7 History
- 8 See also
- 9 References
|This section needs additional citations for verification. (April 2013) (Learn how and when to remove this template message)|
The age of onset of seizures is typically between 2 and 8 years old, though onset can occur at an earlier or later age. The syndrome shows clear parallels to West syndrome, enough to suggest a connection.
Daily multiple seizures are typical in LGS. Also typical is the broad range of seizures that can occur, larger than that of any other epileptic syndrome. The most frequently occurring seizure type is tonic seizures, which are often nocturnal (90%); the second most frequent are myoclonic seizures, which often occur when the person is over-tired.
Atonic, atypical absence, tonic, complex partial, focalized and tonic–clonic seizures are also common. Additionally, about half of patients will have status epilepticus, usually the nonconvulsive type, which is characterized by dizziness, apathy, and unresponsiveness. The seizures can cause sudden falling (or spasms in tonic, atonic and myoclonic episodes) and/or loss of balance, which is why patients often wear a helmet to prevent head injury.
In addition to daily multiple seizures of various types, children with LGS frequently have arrested/slowed psycho-motor development and behavior disorders.
The most common type of LGS (70–78%) is symptomatic (secondary) - that is an identifiable underlying pathology is responsible. This includes encephalopathy (brain damage) or another disease and/or developmental disorder. Frequent causes include tuberous sclerosis, hereditary metabolic diseases, inflammatory brain disease such as encephalitis, meningitis, and toxoplasmosis; hypoxia–ischemia injury and other birth injuries; and lesions of the frontal lobe. These patients tend to have a worse prognosis than those with idiopathic (unknown cause) LGS.
Progress in genome and exome sequencing is revealing that some individuals diagnosed with Lennox Gastaut Syndrome have de novo mutations in a variety of genes, including CHD2, GABRB3, ALG13 and SCN2A The Epi4K study consortium (2013) observed de novo mutations in at least 15% of a study cohort of 165 patients with LGS and Infantile Spasms using whole exome sequencing. A 2013 study by Lund and colleagues found a high frequency of rare Copy Number Variants (CNV's) in adult patients with LGS or LGS-like epilepsy
In up to one-third of cases no cause can be found.
Lennox–Gastaut syndrome and drug resistant/drug refractory epilepsy have been recorded with neurovisceral porphyrias including acute intermittent porphyria, hereditary coproporphyria and variegate porphyria. Care must be taken to avoid porphyrinogenic anti-seizure drugs in these cases. Diagnosis may be difficult in children who require enzyme or DNA testing.
|This section does not cite any sources. (April 2013) (Learn how and when to remove this template message)|
The diagnosis or suspicion of LGS is often a question of probability rather than certainty. This is because the varied presentations of LGS share features with other disorders, many of which may be said to have overlapping characteristics.
The diagnosis is more obvious when the epilepsy has frequent and manifold attacks, with the classic pattern on the electro-encephalogram (EEG); the latter is a slowed rhythm with Spike-wave-pattern, or with a multifocal and generalizing Sharp-slow-wave-discharges at 1.5–2.5 Hz. During sleep, frequently, tonic patterns can be seen. But variations of these patterns are known in patients with no diagnosis other than LGS, and they can differ bilaterally, and from time to time, within the same patient.
General medical investigation usually reveals developmental delay and cognitive deficiencies in children with true LGS. These may precede development of seizures, or require up to two years after the seizures begin, in order to become apparent.
Exclusion of organic or structural brain lesions is also important in establishing a correct diagnosis of LGS; this may require magnetic resonance imaging (MRI) or computerized tomography (CT). An important differential diagnosis is 'Pseudo-Lennox-Syndrome', which differs from LGS, in that there are no tonic seizures; sleeping EEG provides the best basis for distinguishing between the two.
LGS seizures are often treatment resistant, but this does not mean that treatment is futile. Options include anticonvulsants, anesthetics, steroids such as prednisone, immunoglobulins, and various other pharmacological agents that have been reported to work in individual patients.
No scientific study has shown any drug to be highly efficacious for treatment of LGS, and its best treatment remains uncertain. Rufinamide(Banzel), lamotrigine, topiramate and felbamate may help as add-on therapy.[needs update]
- valproates (valproic acid, sodium valproate and valproate semisodium)
- benzodiazepines, specifically clonazepam, nitrazepam, and clobazam
Nitrazepam is not approved in the USA.
Clobazam has been recently approved by the FDA on 10/24/11.
In 1999, Dr. Sachdeo and colleagues at the University of Medicine and Dentistry of New Jersey and the Robert Wood Johnson Medical School in New Brunswick reported that 33% of the patients in a group of patients taking topiramate experienced a minimum 50% reduction in seizures (specifically drop attacks and tonic–clonics), compared with 8% in the placebo group. It was also found to be effective as an adjunctive therapy in a review published by Drs. Edith Alva Moncayo and Antonio Ruiz Ruiz in March 2003.
Dr. Motte and colleagues at the American Memorial Hospital at Reims, France reported in 1997 that lamotrigine was effective in the treatment of LGS, with the most common side effect in the treatment group relative to placebo being colds or viral illnesses. Two years later, it was approved by Health Canada for adjunctive therapy in Lennox Gastaut in adults and children. The United States Food and Drug Administration approved it for that in August 1998.
Felbamate is indicated in the use of LGS in the event that everything else fails, and was found to be superior to placebo in controlling treatment resistant partial seizures and atonic seizures. However, it has been known to cause aplastic anemia and liver toxicity.
Unapproved, off-label, and investigational drugs
Vigabatrin was found by Feucht et al. to be an effective add-on in patients whose seizures were not satisfactorily controlled by valproate. Out of 20 children, only 1 experienced a serious side effect (dyskinesia).
Zonisamide showed promise in an overview of controlled and uncontrolled trials conducted in Japan. However, in a physician survey conducted December 2004, only 28% of Lennox–Gastaut and West syndrome patients improved on zonisamide.
Medical cannabis and/or specifically Cannabidiol. Cannabidiol (CBD) is a compound found in cannabis that may have potential therapeutic use for individuals living with Lennox-Gastaut Syndrome. The compound is said to quiet chemical and electrical activity in the brain without the drawback of effects from cannabis that THC typically includes.
Palliative surgery reduces the severity and generalization of seizures to the whole brain, but does not influence the seizures sources.
In eligible symptomatic patients, who can be validated by brain imaging techniques, curative surgery could remove seizures sources. Depending on the source size, surgery will be a resection (removal of small brain areas), disconnection (larger areas) and in somes case hemispherectomy (a full hemisphere disconnection or removal).
In the past, LGS patients were considered de facto as non eligible for epilepsy curative surgery, as scientists were thinking the LGS was a fully generalized epilepsy in all cases. Since around 2010 this assumption has been reviewed and all surgery options, including curative surgery, must be evaluated. Two studies on LGS patients series who underwent curative surgery in Korea and China, showed very good results, up to seizure freedom (Engel class I) for 80% of these patients below 5 years old, and 40% above 5 years old. Nevertheless, like all epilepsy curative surgeries, seizures may recur in the years following surgery, but surgery allows the child to have better brain development during the seizure free period.
Intravenous immunoglobulin therapy
Intravenous immunoglobulin therapy has been used in Lennox–Gastaut syndrome as early as 1986, when van Rijckevorsel-Harmant and colleagues used it in seven patients with ostensibly idiopathic LGS and saw EEG improvement and decreased seizure frequency in six of them.
The mortality rate ranges from 3-7% in a mean follow up period of 8.5 to 9.7 years. Death is often related to accidents.
Incidence and prevalence
LGS is seen in approximately 4% of children with epilepsy, and is more prevalent in males than females.  Children can have no neurological problems prior diagnosis, or have other forms of epilepsy. West syndrome is diagnosed in 20% of patients before it evolves into LGS at about 2 years old.
According to a 1997 community-based retrospective study in the Helsinki metropolitan area and the province of Uusimaa, the annual incidence of Lennox–Gastaut was 2 in 100,000 (0.002%) from 1975 to 1985.
0.026% of all children in the Atlanta, Georgia metropolitan area were estimated to have LGS in 1997, which was defined as, "onset of multiple seizure types before age 11 years, with at least one seizure type resulting in falls, and an EEG demonstrating slow spike-wave complexes (<2.5 Hz)." The study concluded that LGS accounts for 4% of childhood epilepsies.
In 2010 the first documentary highlighting this disorder was produced by Eisai (company) (a pharmaceutical company making drugs including rufinamide) in cooperation with the LGS Foundation. There are a number of videos available on this YouTube channel: https://www.youtube.com/user/livingwithlgs
Caregivers of individuals living with Lennox-Gastaut Syndrome may seek support and information from a variety of resources including the LGS Foundation and the Epilepsy Foundation of America. The LGS Foundation offers an international conference every 18 months in the United States, regional support groups, online support groups, and numerous other programs and services.
International LGS Awareness Day is November 1 annually.
- Markand, Omkar N. (2003-12-01). "Lennox-Gastaut syndrome (childhood epileptic encephalopathy)". Journal of Clinical Neurophysiology. 20 (6): 426–441. doi:10.1097/00004691-200311000-00005. ISSN 0736-0258. PMID 14734932.
- Archer, John S.; Warren, Aaron E. L.; Jackson, Graeme D.; Abbott, David F. (2014-01-01). "Conceptualizing Lennox–Gastaut syndrome as a secondary network epilepsy". Epilepsy. 5: 225. doi:10.3389/fneur.2014.00225. PMC . PMID 25400619.
- "Childhood seizures – epilepsy and convulsions in children". Archived from the original on April 8, 2005. Retrieved August 16, 2005.
- Tyagi, Satyanand; et al. (Jul–Sep 2010). "Pharmacological Management of Lennox-Gastaut Syndrome a Difficult to Treat Form of Childhood-Onset Epilepsy: An Overview" (PDF). International Journal of Pharma and Bio Sciences. 1 (3): 1–6.
- Trevathan, E; Murphy, CC; Yeargin-Allsopp, M (1997). "Prevalence and descriptive epidemiology of Lennox-Gastaut syndrome among Atlanta children". Epilepsia. 38 (12): 1283–8. doi:10.1111/j.1528-1157.1997.tb00065.x. PMID 9578523.
- Lund C, Brodtkorb E, Øye AM, Røsby O, Selmer KK (2014). "CHD2 mutations in Lennox-Gastaut syndrome". Epilepsy Behav. 33: 18–21. doi:10.1016/j.yebeh.2014.02.005. PMID 24614520.
- LCapelli LP, Krepischi AC, Gurgel-Giannetti J, Mendes MF, Rodrigues T, Varela MC, Koiffmann CP, Rosenberg C (2012). "Deletion of the RMGA and CHD2 genes in a child with epilepsy and mental deficiency". Eur J Med Genet. 55 (2): 132–134. doi:10.1016/j.ejmg.2011.10.004. PMID 22178256.
- Allen AS, Berkovic SF, Cossette P, et al. (2013-09-12). "De novo mutations in the classic epileptic encephalopathies". Nature. 501 (7466): 217–221. doi:10.1038/nature12439. ISSN 0028-0836. PMC . PMID 23934111.
- Lund, Caroline; Brodtkorb, Eylert; Røsby, Oddveig; Rødningen, Olaug Kristin; Selmer, Kaja Kristine (2013-07-01). "Copy number variants in adult patients with Lennox-Gastaut syndrome features". Epilepsy Research. 105 (1-2): 110–117. doi:10.1016/j.eplepsyres.2013.01.009. ISSN 1872-6844. PMID 23415449.
- Hancock, EC; Cross, HH; Hancock, Eleanor C (2009). Hancock, Eleanor C, ed. "Treatment of Lennox-Gastaut syndrome". Cochrane database of systematic reviews (Online) (3): CD003277. doi:10.1002/14651858.CD003277.pub2. PMID 19588340.
- Hakimian S, Cheng-Hakimian A, Anderson GD, Miller JW (August 2007). "Rufinamide: a new anti-epileptic medication". Expert Opin Pharmacother. 8 (12): 1931–40. doi:10.1517/146565188.8.131.521. PMID 17696794.
- Sachdeo, R. C.; Glauser, TA; Ritter, F; Reife, R; Lim, P; Pledger, G (1999). "A double-blind, randomized trial of topiramate in Lennox-Gastaut syndrome". Neurology. 52 (9): 1882–7. doi:10.1212/wnl.52.9.1882. PMID 10371538.
- Alva-Moncayo, E; Ruiz-Ruiz, A (2003). "Utilidad del topiramato como terapia añadida a esquemas convencionales para el síndrome de Lennox-Gastaut" [The value of topiramate used with conventional schemes as an adjunctive therapy in the treatment of Lennox-Gastaut syndrome]. Revista de neurologia (in Spanish). 36 (5): 453–7. PMID 12640599.
- Motte, J; Trevathan, E; Arvidsson, JF; Barrera, MN; Mullens, EL; Manasco, P (1997). "Lamotrigine for generalized seizures associated with the Lennox-Gastaut syndrome. Lamictal Lennox-Gastaut Study Group". The New England Journal of Medicine. 337 (25): 1807–12. doi:10.1056/NEJM199712183372504. PMID 9400037.
- Epilepsy Ontario (1999). "Lamotrigine Approved in Canada for Lennox–Gastaut Syndrome". 'Sharing' News. Retrieved 13 November 2005.
- Glaxo Wellcome Inc (1998). "Final Printed Labeling—Part 1". Lamictal Tablets & Chewable Dispersible Tablets (Lamotrigine) Drug Approval Page. United States Food and Drug Administration Center for Drug Evaluation and Research. Archived from the original on April 29, 2005. Retrieved 13 November 2005.
- "Felbatol (felbamate)". p. 3. Retrieved 2007-09-19.
- The Felbamate Study Group In Lennox-gastaut Syndrome (1993). "Efficacy of felbamate in childhood epileptic encephalopathy (Lennox-Gastaut syndrome). The Felbamate Study Group in Lennox-Gastaut Syndrome". The New England Journal of Medicine. 328 (1): 29–33. doi:10.1056/NEJM199301073280105. PMID 8347179.
- Devinsky, O; Faught, RE; Wilder, BJ; Kanner, AM; Kamin, M; Kramer, LD; Rosenberg, A (1995). "Efficacy of felbamate monotherapy in patients undergoing presurgical evaluation of partial seizures". Epilepsy research. 20 (3): 241–6. doi:10.1016/0920-1211(94)00084-A. PMID 7796796.
- O'neil, MG; Perdun, CS; Wilson, MB; Mcgown, ST; Patel, S (1996). "Felbamate-associated fatal acute hepatic necrosis". Neurology. 46 (5): 1457–9. doi:10.1212/wnl.46.5.1457. PMID 8628501.
- Feucht, M; Brantner-Inthaler, S (1994). "Gamma-vinyl-GABA (vigabatrin) in the therapy of Lennox-Gastaut syndrome: an open study". Epilepsia. 35 (5): 993–8. doi:10.1111/j.1528-1157.1994.tb02544.x. PMID 7925171.
- Yagi, K (2004). "Overview of Japanese experience-controlled and uncontrolled trials". Seizure : the journal of the British Epilepsy Association. 13 Suppl 1: S11–5; discussion S16. doi:10.1016/j.seizure.2004.04.018. PMID 15511680.
- Yamauchi, T; Aikawa, H (2004). "Efficacy of zonisamide: our experience". Seizure : the journal of the British Epilepsy Association. 13 Suppl 1: S41–8; discussion S49. doi:10.1016/j.seizure.2004.04.021. PMID 15511689.
- Douglass, LM (2014). "Surgical options for patients with Lennox-Gastaut syndrome". Epilepsia.
- Lee, Yun Jin (2010). "Resective pediatric epilepsy surgery in Lennox-Gastaut syndrome". Pediatrics.
- Liu, SY (2012). "Surgical treatment of patients with Lennox-Gastaut syndrome phenotype". The Scientific World Journal. PMC .
- Van Rijckevorsel-Harmant, K; Delire, M; Rucquoy-Ponsar, M (1986). "Treatment of idiopathic West and Lennox-Gastaut syndromes by intravenous administration of human polyvalent immunoglobulins". European Archives of Psychiatry and Neurological Sciences. 236 (2): 119–22. doi:10.1007/BF00454021. PMID 3792407.
- Glauser, Tracy A.; Morita, Diego A. (2002). "Introduction". Lennox–Gastaut Syndrome. eMedicine.com, Inc. Retrieved 8 July 2005.
- Heiskala, H (1997). "Community-based study of Lennox-Gastaut syndrome". Epilepsia. 38 (5): 526–31. doi:10.1111/j.1528-1157.1997.tb01136.x. PMID 9184597.