Assessing Risk for Relapse among Children with Infantile Spasms Using the Based Score after ACTH Treatment: A Retrospective Study

Infantile spasm (IS) is a rare early infantile epileptic encephalopathy characterized by epileptic spasms with or without hypsarrhythmia,and with poor prognosis [1]. Prompt cessation of the spasms and resolution of hypsarrhythmia on electroencephalogram (EEG) were thought to be associated with a favorable cognitive outcome [2, 3], as important as the long-term remission of spasms [4]. Adrenocorticotropic hormone (ACTH) is currently the preferred first-line treatment for infantile spasms, but because of the side effects of ACTH therapy, including hypertension, hypokalemia, metabolic alkalosis, irritability, brain atrophy, and serious infection, it cannot be used long term [5]. The short-term response rate of ACTH therapy was 42–87%, but relapse still occurred in nearly half of the children studied [6]. Dressler et al. [7] revealed that the relapse rate was 56% in those patients who responded after receiving ACTH therapy.

EEG is the main diagnostic technique for the precise classification of epileptic seizures and syndromes, and broadly used in studies on epilepsy. For example, the early response and prognosis of infantile spasms can be predicted by analyzing the multiscale entropy or high-frequency oscillations of EEG [8‐11]. The Burden of Amplitudes and Epileptiform Discharges (BASED) score developed by Mytinger et al. [12] is a reliable interictal EEG grading scale for children with infantile spasms. It can help determine the presence or absence of epileptic encephalopathy in the setting of infantile spasms in pretreatment and posttreatment studies. In this convenient and rapid method, clinical electrophysiologists assign a score by examining the EEG recordings with the naked eye without the need for external statistical or analytical tools [12].

Previous studies have concentrated on the short-term response and long-term outcome of ACTH treatment of IS. Despite relapse after ACTH therapy being such an important issue, the factors related to relapse and its prevention have not yet been fully investigated. In this retrospective cohort study, the BASED scale was used to determine whether there was a difference between children with IS who had relapsed and those who had not after short-term response with ACTH treatment. Moreover, the differences and similarities of the groups in brain functional connectivity networks were also explored.

A total of 103 children with IS who had a short-term response with ACTH treatment and returned for follow-up were screened. Among them, 8 non-relapse patients had a follow-up of less than 1 year, 3 children experienced a relapse at the duration of serious infection, and the ASMs of 28 patients were adjusted during follow-up. The 39 patients above were excluded. Finally, a total of 64 children were enrolled in the study (Fig. S1). Among them, 37 children (57.8%) experienced relapse, and the median duration after ACTH treatment was 3 (1.5, 6) months; the other 27 children (42.2%) remained seizure free in the 30 (16, 40) months of follow-up.

There was a statistically significant difference in the BASED score of EEG after ACTH treatment between the two groups (p \(<\) 0.001), but no significant group differences emerged for the other factors (including etiology, presence, or absence of pathogenic structural abnormalities on MRI, age of spasm onset, time from onset to receive ACTH treatment, the dosage of ACTH, the presence or absence of hypsarrhythmia before and after ACTH treatment, respectively, etc.) (Table 1).

In both the relapse group and the non-relapse group, no significant group difference emerged for the BASED score of EEG after ACTH treatment between the two subgroups (definitive etiology versus unknown etiology). Similar results were observed overall in the 64 patients; there was no significant difference in the BASED score of EEG after ACTH treatment between those patients who had definitive etiology and those with unknown etiology ( Table 2).

The results of univariate logistic regression analysis showed that the independent risk factor for relapse was BASED score [p \(<\) 0.001, odds ratio (OR) 2.26, 95% confidence interval (CI) 1.54–3.62] (Table 3). Determinants with p \(\le \) 0.20 in the univariate logistic regression models (presence of hypsarrhythmia after ACTH, definitive or unknown etiology, VPA exposure history, the interval from onset to receive ACTH treatment, presence of hypsarrhythmia before ACTH treatment, BASED score) were included in the multivariate model; the results were consistent with the univariate logistic regression, showing that an elevated BASED score may correlate with a higher risk of relapse (p = 0.001, OR 2.23, 95% CI 1.43–3.83; Table 3).

The results of univariate Cox regression analysis showed that the independent risk factors for relapse were BASED score [p \(<\) 0.001, hazard ratio (HR) 1.56, 95% CI 1.28–1.89], VPA exposure history (p = 0.041, HR 1.97, 95% CI 1.03–3.77) and presence of hypsarrhythmia after ACTH treatment (p = 0.011, HR: 3.18, 95% CI 1.31–7.71; Table 4). Determinants with p ≤ 0.20 in the univariate logistic regression models (presence of hypsarrhythmia after ACTH, definitive or unknown etiology, VPA exposure history, interval from onset to receive ACTH treatment, presence of hypsarrhythmia before ACTH treatment, number of ASMs, BASED score) were included in the multivariate model, indicating that an elevated BASED score may correlate with a higher risk of relapse (p \(<\) 0.001, HR 1.5, 95% CI 1.2–1.9; Table 4, Fig. S2), which was consistent with the multivariate logistic regression. The same result was observed in the cohort of 72 cases (including the 8 patients with non-relapse who were followed up for less than 1 year) (Table S1, Fig. S3).

The BASED score after ACTH treatment has good clinical value (p \(<\) 0.001, AUC: 0.82, 95% CI 0.713–0.925; Fig. 1) for predicting relapse. The optimal cutoff value of the BASED score was 3 (sensitivity 0.893, specificity 0.667, Youden’s index 0.56). There were 27 (42.2%) patients who were free of seizure more than 12 months after the short-term response (Fig. 2a). In total, 89.3% of patients with a BASED score less than or equal to 3 experienced a relapse within 12 months after short-term response, but 33.3% of those patients had a BASED score less than or equal to 2 (p = 0.001, Fig. 2b). Similar results were observed in the 72-case cohort (Figs. S4, S5).

After PSM (factors like presence of hypsarrhythmia after ACTH treatment, VPA exposure history, and interval from onset to receive ACTH; ratio is 1:2), 24 patients with a BASED score \(\ge \) 2 were selected for functional connectivity assessment, where 8 non-relapse and 16 relapses were assigned to the corresponding group.

The intensity of functional connectivity was classified as state 0–4, which grows with increasing quantitative value (Fig. 3a). To examine the temporal trends of these FC states, we used the occurrence as a function of time, defined as the ratio of each state presented in the current time window. We found that the occurrence of state 1 in the non-relapse group tended to be higher than in the relapse group at each corresponding time, while the occurrences of state 3 and state 4 were lower (Fig. 3b). The proportion of state 1 in the relapse group was significantly decreased compared with the non-relapse group, while the proportion of state 3 was significantly increased (p \(<\) 0.05, Fig. 3c). There were significant correlations (corrected by Benjamini–Hochberg procedure) between BASED score and the proportion of functional connectivity (FC) states, particularly states 1 and 3 (Fig. 3d).

Some previous studies suggested the EEG features could be associated with the relapse of IS [7‐10, 20]. Hayashi et al. demonstrated that serial EEG findings after ACTH therapy were significantly related to relapse; the persistence or worsening of epileptic discharges on EEG, especially multifocal epileptic discharges, may indicate a relapse [20]. Tanritanir et al. proposed that the reduction of delta power and delta coherence were greater in sustained responders than in relapsed patients or non-responders with IS treated by ACTH [8]. Wang et al. showed that, after ACTH treatment, the number and channels of high-frequency oscillations (HFOs) were significantly lower, whereas the percentage decrease in the number, spectral power, and channels of ripples was significantly higher in the seizure-free group than in the non-seizure-free group; meanwhile, the relapse subgroup showed a higher number, spectral power, and wider distribution of ripples than did the non-relapse subgroup [9]. The above studies suggest that EEG features are closely related to the relapse of IS.

In the presented study, the EEG results of children with short-term response after ACTH treatment were evaluated by the BASED scoring method, and we found the BASED score was higher in the relapse group than in the non-relapse group. This suggests that those who have a BASED score of 3 or higher have a high risk of relapse even they achieve a short-term response.

Although the disappearance of hypsarrhythmia is traditionally considered to be an important indicator of clinical efficacy and prognosis, its assessment exhibits poor interrater reliability [21]. Some children with IS did not present the typical EEG features [22, 23]. A recent study showed that, among 30 children with IS who experienced relapse, 26 children did not have the typical or modified hypsarrhythmia after ACTH treatment, which suggests that the relapse was not correlated with the presence or absence of hypsarrhythmia [8]. The presence or absence of hypsarrhythmia after ACTH treatment was also investigated in our study; like in the previous study [8], there were no significant differences between the relapse group and non-relapse group. For this reason, hypsarrhythmia after ACTH treatment was not included in the final regression analysis.

Previous studies of IS have suggested it to be an age-related epileptic syndrome with transient age-specific neuronal hyperexcitability [24]. This nature of the disease is one of the hypothesized reasons for the permanent effect of short-course hormonal therapy, even after withdrawal of ACTH treatment [25, 26]. Experience over the past decades has indicated that, if the etiology remains unknown and there is normal psychomotor development before spasm onset, the patient will become seizure free and have normal or nearly normal development in about 80% cases [27‐30], showing that epileptiform activity had been well controlled and the emergence of epileptic encephalopathy was prevented. In our study, the BASED score in the relapse group was higher than in the non-relapse group. As is the nature of the BASED scoring method, the higher the score, the more likely that spasms occur [12]. For this reason, a functional connectivity measure alongside BASED scoring, which showed that the relapse group had stronger, more stable functional networks than the non-relapse group; meanwhile, there were strong associations between the proportions of different functional connectivity intensity and BASED score. Shrey et al. [31] showed that all responders with epileptic spasms exhibited decreases in functional connectivity strength after treatment initiation, while an increase in connectivity strength occurred only in the non-responders. Therefore, we speculate that the significantly higher BASED score observed in the relapse group indicates that the epileptiform activity in those children was not sufficiently and effectively controlled, which led to relapse after short-term response.

The combination of personal history, physical examination, and early imaging yields an identifiable etiology in about 40–55% of cases of IS [1, 32, 33]. There were 46.9% patients with a definitive etiology and 53.1% patients with an unknown etiology in our cohort, which was consistent with previous studies. The etiology (definitive versus unknown) did not differ significantly between the relapse group and the non-relapse group, and it did not have a significant effect on relapse or non-relapse in Cox proportional hazards regression models, which was in line with a recent study by Hayashi et al. [20]. In addition, etiology (definitive versus unknown) is not associated with the BASED score after ACTH treatment. However, it needs to be noted that there was a relatively long time (about 10 years) to accrue patients included in our cohort; thus, owing to the low prevalence of molecular diagnostic techniques in the past, some patients with definitive etiology could have been mistakenly assigned as unknown cases.

Several studies have shown that patients with structural anomalies on MRI have a poor prognosis, such as a lower incidence of short-term response and long-term seizure freedom [6, 33]. In our cohort, all children underwent brain MRI examination. The presence or absence of pathogenic structural abnormalities on MRI did not differ significantly between the relapse group and non-relapse group, and it also did not have a significant effect in Cox proportional hazards regression models.

In line with the previous study [6], the interval from ACTH treatment to relapse was 3 (1.5, 6) months in our study. The rate of relapse in our cohort was 57.8%, which is higher than in previous studies [6, 20, 34‐36]. This may have been caused by the strict inclusion criteria, which were implemented to avoid missing subtle spasms that are difficult to identify (such as episodes of yawning, gasping, facial grimacing, isolated eye movements, and transient focal motor activity). Only the patients with non-relapse who were readmitted to our hospital could be included, which also may have led to some patients with non-relapse being excluded .

Our study also has some limitations. The strength of the conclusions of this study was limited by its sample size. In addition, there was also potential bias generated during patient selection owing to the strict inclusion and exclusion criteria. Finally, we did not perform a more detailed classification of etiology. Future studies are needed to overcome these limitations, and we hope our study will motivate other investigators to replicate and extend these findings.

In conclusion, our study suggests that the BASED score after ACTH treatment may be predictive of relapse after short-term response. Patients with IS who have a BASED score greater than or equal to 3 seem to have a higher risk of relapse, and they may exhibit EEG abnormal functional connections.