The current study compared the effectiveness, speed of action, and safety profile characteristics of intravenous methylprednisolone pulse therapy versus oral prednisolone in infants with epileptic spasms.
There was a minor male prevalence of IS in our study, which was previously reported by Velek and Velková in their review , but was more prominent in Kapoor et al.  and Rajpurohit et al.  studies. Importantly, both groups were age-matched during the 1st year of life (infancy), which corresponds to the ILAE criteria of IS.
The age of onset of spasms was between 3 and 7 months as in previous reports [1, 6]. The etiology of IS was unknown in about two-thirds of cases in our study, while it is usually unknown in only one-third of cases as stated in the review of Velíšek and Velíšková . The majority of the cases in Kapoor et al.  and Rajpurohit et al.  studies were related to neonatal hypoglycemia and perinatal asphyxia. These discrepancies may be due to variable randomization and changes in diagnostic tool availability, particularly advancements in genetic testing (which is not done in our study), as numerous genes may contribute to the bulk of unknown etiologies, as noted by Velek and Velková .
About half of the patients have comorbidities, with developmental delay being the more prevalent which when combined with hypsarrhythmia completed the triad of West syndrome . Microcephaly was in a minority of cases (13.2%) while vision and hearing deficits were the least (3.8% for each). These findings differ with findings of Kapoor et al. as in their study each of microcephaly and developmental delay was present in about two-thirds of cases, while each of hearing and vision deficit was present in about one-third of cases . In Rajpurohit et al. study, developmental delay was present in more than three-fourths of cases . This disparity may be explained by the fact that the etiologies in cohorts are different.
For many years, IVMP and OP were used interchangeably to treat a variety of drug-resistant epilepsies, including West syndrome, Landau–Kleffner syndrome, epileptic encephalopathies, and absence epilepsy, with varying regimens [6, 7, 14].
In our study, both groups received regimens for approximately 6 weeks, and the various clinical characteristics and etiologies were distributed nearly evenly between them.
Prior to treatment, the frequency of spasms was nearly identical in both groups.
The prevalence of spasm cessation after treatment initiation was similar in both groups at 7 and 14 days. It was 53.8% in group A and 51.9% in group B at 7 days which agrees with other studies [6, 7, 12, 14]. In their study, Hassanzadeh and Aminzadeh used intravenous IVMP in a cohort of 20 children and observed clinical remission in 60% of them at 4.41 ± 1.50 days . Mytinger et al. reported their experience with use of IVMP pulse followed by an 8-week course of oral steroids in 10 participants with IS. Remission was achieved in 50% between 2 and 6 days . Yeh et al. used IVMP followed by a short course of oral steroids and observed that in nine of 14 patients (64.3%), rapid cessation of spasms occurred with mean time to cessation of 3.0 days . Kapoor et al. found early response in IVMP group, as 54.8% showed spasm cessation at 5.4 ± 0.9 days, while 68.9% of the OP group needed 9.5 ± 2.6 days to show spasms cessation . In Rajpurohit et al. study which included 44 recently diagnosed children with WS, methylprednisolone therapy was given as intravenous infusion to 18 children at a dose of 30 mg/kg/day for 5 days followed by oral steroids 1 mg/kg gradually tapered over 5–6 weeks, by day 14 of therapy, 6/18 (33.3%) children achieved cessation of epileptic spasms .
With regard to resolution of hypsarrhythmia in EEG, it was also similar in our study between both groups with a total of 37.7% of infants. EEG showed improvement at 2 weeks, while 47.2% showed improving EEG at 6 weeks. In Hassanzadeh and Aminzadeh study of IVMP, resolution of hypsarrhythmia on follow-up EEG at 2 weeks was observed in 65% of patients  while 50% of infants in Mytinger et al. study achieved this resolution in a mean time of 23 days: range 11–38 days . In Kapoor et al. study, 51.6% of IVMP group and 44.8% of OP group showed resolution of hypsarrhythmia at 2 weeks which is comparable to our study as the percentage was 42.3% in group A and 33.3% in group B .
At 6 weeks, the improvement of EEG was 46.2% in group A and 48.1% in group B which also coincides to a great extent with Kapoor et al. results where the percentage was 45.2% and 75.9%, respectively . The similarity in EEG results in the two groups in our study, while its difference in Kapoor et al. study could be explained by the similar duration of treatment in our groups while it was shorter in Kapoor et al. study in IVMP group.
The relatively high dose in OP group may explain the higher response in our study relative to other studies with lower oral doses. Trials using 2 mg/kg/day of oral prednisone had remission rates of 8.3–28.6% [15, 16].
Lux et al., who used higher doses of oral prednisolone (ranging from 5 to 8 mg/kg/day), reported a 70% remission rate 
The higher response rate was in new patients in both groups than in patients receiving other medication prior to steroids which coincides with the results of Mytinger et al. .
The most common adverse effect was increased appetite followed by weight gain which was nearly similar in both groups. These two side effects were more common in OP group in Kapoor et al. study but as stated above the duration of treatment was longer in this group in his study than in their IVMP group .
Sleep disturbances were less but nearly the same in both groups followed by irritability then hypertension. This agrees with Yeh et al. and Hassanzadeh and Aminzadeh who used IVMP [7, 14] but disagrees with Kapoor et al. who noted that these three were found significantly in the first few days of treatment in IVMP group and related this to their regimen .
GIT disturbances were similar in both groups in our study but was more than those in Kapoor et al. study which may be explained by the relatively longer duration of treatment in our regimen especially in IVMP group and other dietary habits which may contribute to these adverse effects .
Hyperglycemia was similar in both groups coinciding with the results of Kapoor et al. study .
First, it was not a blind or randomized study (rational: We were afraid to lose follow-up of cases (especially with small sample size), in addition to money and time constrains, and inability to measure the long-term outcome of both therapies. Also, validity of blind and randomized trials requires multiple sites, which would be difficult to manage). Second, the response to treatment was dependent mainly on parental report and not on objective 24-h EEG monitoring. Third, the etiology was unknown in most patients while different etiologies may influence prognosis. Lastly, we did not measure the long-term outcome of both therapies.