Abstracts

Rationale: The most recent consensus statement regarding the treatment of infantile spasms states, ACTH or VGB may be useful for short-term treatment of infantile spasms, with ACTH considered preferentially over VGB. Hormonal therapy may be considered for use in preference to VGB in infants with cryptogenic infantile spasms Recent survey of child neurologists in US revealed diverse treatments, which includes anticonvulsants not endorsed by the above practice parameter. To understand the clinical variables which effect treatment allocations, we retrospectively analyzed initial treatment choice and short term treatment outcome in infantile spasms at our institution over 3 year period.Methods: Our study population was selected using ICD-9 code for infantile spasms on discharge diagnosis from September 2009 Sepetember 2012. Patients born prior to January 2008 were excluded. Only patients with the clinical diagnosis and/or EEG diagnosis of hypsarrhythmia were included. Date of diagnosis was defined as date of EEG confirmation of hypsarrhythmia. Short-term remission was defined as resolution of spasms AND no hypsarrhythmia on EEG at 3 months.Results: At our institution, the most common initial therapy was Vigabatrin which was used in 61% (41/66) of patients. The second most common initial therapy was other anticonvulsants, such as topiramate and valproic acid, in 29% (19/66) of patients. Hormonal therapies, such as ACTH and prednisolone, were the initial therapy in only 9% (6/66) of patients. Short-term remission rates after initial medication choice was found to be 50% (18/36) in vigabatrin group, 0% (0/17) in other anticonvulsant group, and 80% (4/5) in hormone group. 8 patients were lost to follow up. Overall remission rates based on medication (1st, 2nd, or 3rd line) was found to be 67% (8/12) of patients treated with ACTH, 57% (4/7) patients treated with prednisolone, and 45% (21/26) of patients treated with vigabatrin. There was a strong association between etiology and choice of initial medication. Children with unknown etiology got steroids more often that others (4/17 vs. 2/49, p=<0.01). Neither steroids nor VGB was chosen for 18/49 symptomatic patients as an initial treatment choice. Short-term remission rate overall was 55% (32/58). When broken down by etiology, remission rates were found to be 73% (11/15) in patients with cryptogenic etiology and 49% (21/43) in patients with symptomatic etiology. Conclusions: In the treatment of infantile spasms, there is preferential consideration given to vigabatrin at our center. ACTH and prednisolone should be considered as equally efficacious if not superior to vigabatrin for short-term remission of infantile spasms. There is a discrepancy in the treatment choices for patients with symptomatic etiology. The published guidelines from 2012 are ambiguous regarding the management of patient s with symptomatic infantile spasms. This contributes to disparity in their care. The results of this study were discussed during our divisional quality assessment meeting which led to a standardized treatment and follow up protocol at our institution.