Ketogenic diet therapies, including the classic ketogenic diet, modified Atkins diet, and low glycaemic index treatment, have shown effectiveness in controlling seizures, in part by shifting metabolism from glucose to ketone bodies. They improve mitochondrial function, reduce neuroinflammation, and modulate neurotransmitters. Ketogenic diet therapies also affect the gut microbiome, potentially impacting neurotransmitter balance in ways that contribute to seizure control. A classic ketogenic diet is effective yet restrictive, whereas the modified Atkins diet and low glycaemic index treatment offer greater flexibility, tolerability, and ease of implementation, particularly in resource-limited settings. Cochrane reviews and meta-analyses rank the certainty of randomised controlled trial evidence for ketogenic diet therapies as limited. Early initiation of ketogenic diet therapies, particularly in children or patients with metabolic epilepsies, improves seizure outcomes, potentially preventing further mitochondrial and neuronal damage and reducing the risk of developing resistance to antiseizure medications. Research using rigorous, large-scale comparative effectiveness study designs that accounts for differences in age, epilepsy type, dietary therapy modality, sociodemographic background, care delivery contexts, and that minimises performance and observation bias is needed to resolve remaining uncertainties regarding the efficacy and real-world challenges of ketogenic diet therapies in epilepsy.

Epilepsy with myoclonic and atonic seizures (EMAtS), also known as Doose syndrome, accounts for 1%-2% of childhood epilepsies, and various genes have been implicated in causing this epilepsy syndrome. NUS1 encodes for Nogo-B receptor (NgBR), which stabilizes the dehydrodolichyl-diphosphate synthase complex in the endoplasmic reticulum, promoting its enzymatic activity (cis-IPTase) and thereby regulating cholesterol biosynthesis. Pathogenic variants in NUS1 have been associated with movement disorder and epilepsy; however, the spectrum of epilepsy and electroencephalogram (EEG) phenotype has not been well characterized. We describe a single-center case series of five patients with NUS1-related disorder. In our cohort, three patients met the diagnostic criteria of EMAtS, and the remainder had a milder form of generalized epilepsy. Four patients had a pathogenic variant in NUS1 on one allele, and one patient had a missense change of unclear significance but fit the phenotype of NUS1-related disorder. All patients bearing the pathogenic variants in NUS1 had normal to mild developmental delay at the onset of epilepsy, with normal brain magnetic resonance imaging. Age of seizure onset in these patients was 1-7 years, and patients responded to levetiracetam and/or valproic acid. The EEG findings for these patients included the presence of spike and slow wave discharges, as well as the presence of generalized, invariant monomorphic theta range activity in the awake state, which was seen in four out of the five patients. Taken together, NUS1 variants are associated with generalized epilepsy phenotype and an invariant EEG pattern of monomorphic theta activity.

Epilepsy with myoclonic-atonic seizures, formerly myoclonic-astatic epilepsy or Doose syndrome, accounts for 1-2.2% of childhood-onset epilepsies. We investigated genetic determinants, long-term clinical outcomes and prognostic indicators in a large cohort using homogeneous inclusion criteria. We studied 60 patients (26.7% female), mean age 14.5 years (±9.1, range 3.2-41), followed between 1986 and 2024 at two paediatric neurology centres. Average follow-up was 11.7 years. Inclusion criteria were seizure onset between 6 months and 8 years, generalized 2-6 Hz spike-wave discharges and video-EEG documented myoclonic-atonic, myoclonic seizures or both. We analysed clinical, EEG, neuroimaging, neuropsychological and genetic data obtained with next-generation sequencing. We used χ² test, t-test, Log-rank test, Cox regression, population-averaged logistic models and Benjamini-Yekutieli procedure to identify predictors of seizure outcome, intellectual disability and other neurodevelopmental comorbidities. We observed myoclonic-atonic seizures in 55/60 (91.7%), tonic-vibratory seizures in 44/60 (73.4%), absence seizures in 30/60 (50%), myoclonic seizures without post-myoclonic atonia in 25/60 (42%) and non-convulsive status epilepticus in 13/60 (21.7%). A 'stormy' onset occurred in 26/60 patients (43.3%). The most effective drugs were valproate, ethosuximide, benzodiazepines and phenobarbital, used in different combinations, whereas the newer drugs offered no benefit. Long-term outcomes were variable. Thirty-seven patients (61.7%) achieved seizure freedom after 5.1 years on average. We observed drug resistance in 23/60 patients (38.3%) and intellectual disability in 35/60 (58.3%). One adult patient died (mortality rate 1.80/1000-person-years). Attention deficit hyperactivity disorder was the most common comorbidity (24/60, 40%). 'Stormy' onset did not predict a worse prognosis. Global developmental delay at epilepsy onset was associated with drug resistance (P = 0.004, Q = 0.064) and with intellectual disability (P = 0.003, Q = 0.048). We found pathogenic variants in 15/39 (38.5%) patients undergoing next-generation sequencing, including four genes novel for this syndrome (KMT2E; POGZ; SHANK3; YWHAG), with exome sequencing yielding higher diagnostic rates than gene panels. Epilepsy with myoclonic-atonic seizures is a complex syndrome with diverse genetic causes and variable seizure severity and outcomes. Our findings expand its genetic landscape and highlight the prognostic value of prompt overall neurodevelopmental assessment at clinical onset. Whole exome sequencing should be prioritized for early diagnosis and counselling.

Epilepsy is a common finding in children with autism spectrum disorders (ASD), but few studies describe the characteristics of epilepsy in these children. Our study aimed to characterize the electroclinical features of children with ASD and epilepsy through a retrospective multicenter study. Patients with ASD who subsequently developed epilepsy seen at nine pediatric neurology departments were included. Patients with developmental and epileptic encephalopathies (DEE), chronic neurological diseases with epilepsy who developed autism, and those with non-epileptic paroxysmal disorders were excluded. Overall, 74 patients were included, accounting for 15 % of 494 children with ASD seen between 2015 and 2023; 39 were female (52.7 %) and 35 male (47.3 %). Focal epilepsies were identified in 43 patients (58.1 %), which were non-self-limited in 24 and self-limited in 19. Generalized epilepsies were observed in 19 (25.7 %), including six with generalized tonic-clonic seizures alone (one in childhood, five in adolescence), nine with juvenile myoclonic epilepsy, one with childhood absence epilepsy, and three with juvenile absence epilepsy. Eight patients (10.8 %) had epileptic encephalopathies: EE-SWAS in six and epilepsy with myoclonic atonic seizures in two. Four patients (5.4 %) had combined focal and generalized epilepsy. No significant differences were found between epilepsy syndrome or type of epilepsy, seizure type, and comorbidities. No specific epilepsy phenotype was identified in our patients with ASD; the types of epilepsy and syndromes were similar to those seen in the general population. Management should address both epilepsy and the broader complexities of ASD through an integrated approach.