O Tarta-Arsene

Current use of imaging and electromagnetic source localization procedures in epilepsy surgery centers across Europe

In 2014 the European Union–funded E‐PILEPSY project was launched to improve awareness of, and accessibility to, epilepsy surgery across Europe. We aimed to investigate the current use of neuroimaging, electromagnetic source localization, and imaging postprocessing procedures in participating centers.

Recessive loss-of-function mutations in AP4S1 cause mild fever-sensitive seizures, developmental delay and spastic paraplegia through loss of AP-4 complex assembly

We report two siblings with infantile onset seizures, severe developmental delay and spastic paraplegia, in whom whole-genome sequencing revealed compound heterozygous mutations in the AP4S1 gene, encoding the σ subunit of the adaptor protein complex 4 (AP-4). The effect of the predicted loss-of-function variants (p.Gln46Profs*9 and p.Arg97*) was further investigated in a patients fibroblast cell line. We show that the premature stop mutations in AP4S1 result in a reduction of all AP-4 subunits and loss of AP-4 complex assembly. Recruitment of the AP-4 accessory protein tepsin, to the membrane was also abolished. In retrospect, the clinical phenotype in the family is consistent with previous reports of the AP-4 deficiency syndrome. Our study reports the second family with mutations in AP4S1 and describes the first two patients with loss of AP4S1 and seizures. We further discuss seizure phenotypes in reported patients, highlighting that seizures are part of the clinical manifestation of the AP-4 deficiency syndrome. We also hypothesize that endosomal trafficking is a common theme between heritable spastic paraplegia and some inherited epilepsies.

Current standards of neuropsychological assessment in epilepsy surgery centers across Europe

We explored the current practice with respect to the neuropsychological assessment of surgical epilepsy patients in European epilepsy centers, with the aim of harmonizing and establishing common standards. Twenty‐six epilepsy centers and members of “E‐PILEPSY” (a European pilot network of reference centers in refractory epilepsy and epilepsy surgery), were asked to report the status of neuropsychological assessment in adults and children via two different surveys. There was a consensus among these centers regarding the role of neuropsychology in the presurgical workup. Strong agreement was found on indications (localization, epileptic dysfunctions, adverse drugs effects, and postoperative monitoring) and the domains to be evaluated (memory, attention, executive functions, language, visuospatial skills, intelligence, depression, anxiety, and quality of life). Although 186 different tests are in use throughout these European centers, a core group of tests reflecting a moderate level of agreement could be discerned. Variability exists with regard to indications, protocols, and paradigms for the assessment of hemispheric language dominance. For the tests in use, little published evidence of clinical validity in epilepsy was provided. Participants in the survey reported a need for improvement concerning the validity of the tests, tools for the assessment of everyday functioning and accelerated forgetting, national norms, and test co‐normalization. Based on the present survey, we documented a consensus regarding the indications and principles of neuropsychological testing. Despite the variety of tests in use, the survey indicated that there may be a core set of tests chosen based on experience, as well as on published evidence. By combining these findings with the results of an ongoing systematic literature review, we aim for a battery that can be recommended for the use across epilepsy surgical centers in Europe.

Practical clues for diagnosing WWOX encephalopathy

The WW domain-containing oxidoreductase gene is implicated in autosomal recessive disorders of the central nervous system, expressed either as spinocerebellar ataxia or as a severe form with early-infantile epileptic encephalopathy. Here, we describe the electroclinical evolution of these disorders, adding new diagnostic clues based on a case study. The patient, a boy with early-onset epilepsy, presented with profound global developmental delay, persistent hypsarrhythmia, and epileptic spasms, associated with progressive cerebral atrophy without microcephaly. Metabolic disease was excluded. Whole-exome sequencing showed mutations in the WW domain-containing oxidoreductase gene. Our findings extend the phenotypic traits of this aggressive epileptic encephalopathy, with persistent epileptic spasms and hypsarhythmia as a part of the electroclinical phenotype, demonstrating that microcephaly is not mandatory for diagnosis, even when associated with progressive cerebral atrophy. These mutations might be more frequent than expected among early-onset epileptic encephalopathies. We present practical clues for the diagnosis of WWOX encephalopathy in order to avoid unnecessary investigations and ensure appropriate genetic counselling for the families.

OC-5 What is this? can video recordings help?

Video Recordings are very useful in the clinical practice. Most times physicians should diagnose their patients based on descriptions coming from parents or other family members that are emotionally involved. It is very difficult to differentiate some entities in this circumstances. This is why many times there are patients who receive unnecessary treatment or, on the contrary, are deprived of useful remedies. The presenter aims a practical and interactive discussion based on videos and case presentations underlying the role of home video and of video-EEG recording methods. Different non-epileptic and epileptic events will be presented and key recognition issues will be underlined.

OC-51 Tips and tricks in movement disorders in children – the paediatric neurologist perspective-

Movement disorders are neurological syndromes affecting either the voluntary movements, or implying abnormal postures and also a large category of involuntary movements. The movement disorders in children are difficult to classify and describe and most of the time need repeated video visualisation. In children the difficult part is to establish the main symptom, the dominant movement disorder, taking into consideration the variable pattern of symptoms with age and also in the context of the causative disease progression. The aim of the presentation is to help distinguish between different movement disorders, emphasising clinical clues and key-investigations which could offer a rapid aetiology orientation. Acute or chronic movement disorders, permanent or episodic, progressive or not will be exemplified through cases from the experience of a tertiary clinic of paediatric neurology. What would the algorithm of investigation of the ataxic child should be? What questions should be asked when facing a child with acute onset or at the other end of the spectrum – a progressive ataxia? Acute intoxication, opsoclonus-myoclonus, ataxia-telangiectasia, neuronal ceroid lipofuscinosis will be examples for these situation. The extrapyramidal, dyskinetic child will be presented in various instances – the chronic presentation being a sign in many neurometabolic conditions: Lesch-Nyhan, monocarboxylate transporter 8 deficiency, glutaric aciduria type 1, mitochondrial and neurotransmitters disorders will be a few examples of different situations. Conclusion The semiological recognition of the patterns of abnormal movements and the model of evolution help the etiological diagnostic, the history taken from patient and family and the videos being very useful for identifying correctly the abnormal movement. In approaching a child with movement disorder we should think simple, in well defined steps, starting from simple investigations and moving forward in an individualised manner. Early diagnosis might allow early treatment, anticipatory management of complications, sometimes improving outcome and ultimately the quality of life and also would allow in a number of cases genetic advise for the affected families.

P138 – 3000: Neonatal brachial plexus palsy – Romanian single centre experience over 6 years

Objective The aim of this poster is to analyze the cohort of patients with NBPP followed in the Pediatric Neurology Department, to identify specific clinical signs, investigations, outcome and to establish a protocol of diagnosis and follow-up for children with NBPP, according to the actual international recommendations adapted to the local needs. Methods The archive of Pediatric Neurology Clinic was retrospectively analyzed over a 6.5 years period (January 2007–July 2013), selecting the patients with NBPP. Clinical data, information about physical therapy, EMG and MRI results (if needed) were extract from the files and Active motor scale, Toronto score and protocol for obstetrical brachial plexus palsy (Hospital for Sick Children Seattle), were retrospectively applied. Also a questionnaire designed by us was applied for evaluation of present neurological status. Results A cohort of 28 cases evaluated in our clinic between Jan 2007-July 2013 was analyzed. 17 (60.7%) of the patients were boys and 11 (39.2%) were girls. 14 (50%) had right brachial plexus palsy, 12 (42.8%) had left brachial plexus palsy and 2 (7.1%) had bilateral involvement. 5 (17.8%) of them had reconstructive surgery. 11 (39.2%) had good to complete recovery with physical therapy. Conclusion A better information of the parents and doctors concerning the steps of evaluation of this diseases and importance of early diagnosis and compliance with the treatment protocol is critical for a better outcome and for avoiding permanent deficit. This is a pilot study, with a proposal of protocol for diagnosis and treatment, according to the international protocols in force, but prospective studies are mandatory to complete and refresh the existent data.

P25 – 2072 Diagnostic clues and difficulties in Dravet syndrome starting from 34 Dravet patients analysis within Romanian Research Group for Rare Genetic Epilepsies

Objectives: Antiepileptic drugs, such as carbamazepine, often increase the serum concentrations of serum lipids. Studies evaluating the effect of levetiracetam (LEV), a newer broad spectrum antiepileptic agent, on serum lipid levels are very limited. The aim of this study was to investigate prospectively the effect of LEV monotherapy on serum lipid profile in children with epilepsy. Material and methods: The study population consisted of 20 children (8 males, 12 females, aged 2 to 15 years old, mean age 6.5±4.16 years) with epilepsy treated with LEV monotherapy. None of the children were receiving any form of AED medication prior to LEV initiation. Serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TGs), high-density lipoprotein cholesterol (HDL-C), apolipoprotein AI (apo A-I), apolipoprotein B (apo B) and lipoprotein (a) [Lp(a)] were evaluated in all children, before and at 2 and 6 months of LEV monotherapy. Results: TC and HDL-C were significantly increased at 6 (p=0.011 and p=0.012, respectively) months of LEV treatment. There were no significant alterations in LDL-C, TGs, apo A-I, apo B and Lp(a) levels during the study. Conclusions: LEV monotherapy may cause significant alterations in TC, and HDL-C levels in children with epilepsy, occurring early in the course of treatment. Long-term, large, prospective studies are required to clarify the possible effect of LEV on serum lipid profile, the underlying mechanisms involved and its clinical significance.