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Roy B, Ogren JA, Allen LA, Diehl B, Sankar R, Lhatoo SD, Kumar R, Harper RM. Brain gray matter changes in children at risk for sudden unexpected death in epilepsy. Pediatr Res 2024:10.1038/s41390-024-03295-0. [PMID: 38992155 DOI: 10.1038/s41390-024-03295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Potential failing adult brain sites, stratified by risk, mediating Sudden Unexpected Death in Epilepsy (SUDEP) have been described, but are unknown in children. METHODS We examined regional brain volumes using T1-weighted MRI images in 21 children with epilepsy at high SUDEP risk and 62 healthy children, together with SUDEP risk scores, calculated from focal seizure frequency. Gray matter tissue type was partitioned, maps normalized, smoothed, and compared between groups (SPM12; ANCOVA; covariates, age, sex, and BMI). Partial correlations between regional volumes and seizure frequency were examined (SPM12, covariates, age, sex, and BMI); 67% were at high risk for SUDEP. RESULTS The cerebellar cortex, hippocampus, amygdala, putamen, cingulate, thalamus, and para-hippocampal gyrus showed increased gray matter volumes in epilepsy, and decreased volumes in the posterior thalamus, lingual gyrus, and temporal cortices. The cingulate, insula, and putamen showed significant positive relationships with focal seizure frequency indices using whole-brain voxel-by-voxel partial correlations. Tissue volume changes in selected sites differed in direction from adults; particularly, cerebellar sites, key for hypotensive recovery, increased rather than adult declines. CONCLUSION The volume increases may represent expansion by inflammatory or other processes that, with sustained repetitive seizure discharge, lead to tissue volume declines described earlier in adults. IMPACT Children with epilepsy, who are at risk for Sudden Unexplained Death, show changes in brain volume that often differ in direction of change from adults at risk for SUDEP. Sites of volume change play significant roles in mediating breathing and blood pressure, and include areas that serve recovery from prolonged apnea and marked loss of blood pressure. The extent of volume changes correlated with focal seizure frequency. Although the underlying processes contributing to regional volume changes remain speculative, regions of tissue swelling in pediatric brain areas may represent transitory conditions that later lead to tissue loss in the adult condition.
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Affiliation(s)
- Bhaswati Roy
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Jennifer A Ogren
- Department of Neurobiology, University of California at Los Angeles, Los Angeles, CA, 90095, USA
| | - Luke A Allen
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK
| | - Raman Sankar
- Department of Neurology and Pediatrics, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Samden D Lhatoo
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rajesh Kumar
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- Brain Research Institute, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- Department of Radiological Sciences, University of California Los Angeles, Los Angeles, CA, 90095, USA.
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA, 90095, USA.
| | - Ronald M Harper
- Department of Neurobiology, University of California at Los Angeles, Los Angeles, CA, 90095, USA
- Brain Research Institute, University of California Los Angeles, Los Angeles, CA, 90095, USA
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2
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Michelson AD, Frelinger Iii AL, Haynes RL, Kinney HC, Gremmel T. Platelet Pathophysiology: Unexpected New Research Directions. Semin Thromb Hemost 2024. [PMID: 38889800 DOI: 10.1055/s-0044-1787663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
- Alan D Michelson
- Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Andrew L Frelinger Iii
- Division of Hematology/Oncology, Boston Children's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Robin L Haynes
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hannah C Kinney
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
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3
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Kawai C, Kondo H, Miyao M, Sunada M, Ozawa S, Kotani H, Minami H, Nagai H, Abiru H, Yamamoto A, Tamaki K, Nishitani Y. Fatal cardiac dysfunction in a child with Williams syndrome. Leg Med (Tokyo) 2024; 67:102387. [PMID: 38154310 DOI: 10.1016/j.legalmed.2023.102387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/24/2023] [Accepted: 12/25/2023] [Indexed: 12/30/2023]
Abstract
Williams syndrome (WS) is a rare genetic disorder caused by a microdeletion of chromosome 7q11.23. Although the mortality rate of patients with WS is not very high, sudden cardiac death can occur, particularly in cases complicated by coronary artery stenosis. A 3-month-old female infant with supravalvular aortic stenosis and peripheral pulmonary stenosis was discovered unconscious in bed by her mother. She was immediately transferred to an emergency hospital but succumbed despite multiple attempts as resuscitation. DNA microarray analysis revealed microdeletions of 7q11.23 and 16p11.2, confirming WS and unexpectedly identifying 16p11.2 deletion syndrome which is known to be associated with neurodevelopmental disorders. Postmortem computed tomography revealed a severely enlarged heart, indicative of cardiac dysfunction. External examination revealed moderate-to-severe developmental delays in height and body weight. The heart, on internal examination, revealed whitish-discolored lesions; histologically severe fibrotic changes and thickening of the intima in the coronary arteries and aorta. In the brain, the dentate gyrus of the hippocampus appeared malformed. Taken together, these findings suggest that the cause of death was cardiac dysfunction due to WS. In addition, it could be possible that 16p11.2 deletion syndrome and dentate gyrus malformation contributed to her death. Future autopsy studies are warranted to clarify the precise role of microdeletion disorders in sudden death to reduce future preventable deaths in children.
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Affiliation(s)
- Chihiro Kawai
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hidehito Kondo
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Masashi Miyao
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Mariko Sunada
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Seiichiro Ozawa
- Department of Pediatrics, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Hirokazu Kotani
- Forensic Medicine and Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hirozo Minami
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideki Nagai
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hitoshi Abiru
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Yamamoto
- Center for Medical Education, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keiji Tamaki
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoko Nishitani
- Department of Forensic Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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4
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Goldstein RD, Poduri A. Seizures and Sudden Death Beyond SUDEP. Neurology 2024; 102:e208119. [PMID: 38175993 DOI: 10.1212/wnl.0000000000208119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 01/06/2024] Open
Abstract
Many physicians and researchers are familiar with the tragic phenomenon known as sudden infant death syndrome (SIDS), the leading cause of postneonatal mortality in high-resource countries. A less familiar category of unexplained deaths is the problem of sudden unexplained death in childhood (SUDC), a more rare and unusual presentation of sudden death in children who are no longer infants and whose reasons for death defy explanation. A substantial body of research in SUDC now supports the possibility of an overlap with epilepsy and associated sudden death in that context (SUDEP). Stemming from the first contemporary reports of SUDC, we have learned that a disproportionate number of these children have personal and/or family histories of febrile seizures,1 in many cases, inherited in an autosomal dominant manner.2 Their febrile seizures can be associated with abnormalities in their temporal lobes,3,4 including bilamination of the dentate gyrus and other findings conventionally associated with temporal lobe epilepsy, implicating potential epilepsy-related mechanisms.5 Further evaluation of this emerging epilepsy-related phenotype has led to the identification of genetic variants in SCN1A and other epilepsy-associated genes,6,7 moving SUDC away from being considered an unexplained phenomenon to one where the working hypothesis includes a role for genetic predisposition and epilepsy-like mechanisms in the deaths, even without an established history of epilepsy. Nonetheless, because the terminal events of these seemingly healthy children are unexpected and unobserved, the clinical manifestations of whatever underlying vulnerabilities exist-generally discovered posthumously-remain a matter of speculation.
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Affiliation(s)
- Richard D Goldstein
- From the Departments of Pediatrics (R.D.G.) and Neurology (A.P.), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Annapurna Poduri
- From the Departments of Pediatrics (R.D.G.) and Neurology (A.P.), Boston Children's Hospital and Harvard Medical School, Boston, MA
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5
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Oura P, Hakkarainen A, Sajantila A. Forensic neuropathology in the past decade: a scoping literature review. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00672-9. [PMID: 37439948 DOI: 10.1007/s12024-023-00672-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/14/2023]
Abstract
While there has been notable research activity in the field of clinical neuropathology over the recent years, forensic approaches have been less frequent. This scoping literature review explored original research on forensic neuropathology over the past decade (January 1, 2010, until February 12, 2022) using the MEDLINE database. The aims were to (1) analyze the volume of research on the topic, (2) describe meta-level attributes and sample characteristics, and (3) summarize key research themes and methods. Of 5053 initial hits, 2864 fell within the target timeframe, and 122 were included in the review. Only 3-17 articles were published per year globally. Most articles originated from the Europe (39.3%) and Asia (36.1%) and were published in forensic journals (57.4%). A median sample included 57 subjects aged between 16 and 80 years. The most common research theme was traumatic intracranial injury (24.6%), followed by anatomy (12.3%) and substance abuse (11.5%). Key methods included immunotechniques (31.1%) and macroscopic observation (21.3%). Although a number of novel findings were reported, most were of preliminary nature and will require further validation. In order to reach breakthroughs and validate novel tools for routine use, more research input is urged from researchers across the world. It would be necessary to ensure appropriate sample sizes and make use of control groups.
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Affiliation(s)
- Petteri Oura
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, Helsinki, FI-00014, Finland.
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, FI-00271, Finland.
| | - Antti Hakkarainen
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, Helsinki, FI-00014, Finland
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, FI-00271, Finland
| | - Antti Sajantila
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, P.O. Box 21, Helsinki, FI-00014, Finland
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, Helsinki, FI-00271, Finland
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6
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Rabe H, Mercer J. Knowledge gaps in optimal umbilical cord management at birth. Semin Perinatol 2023:151791. [PMID: 37357042 DOI: 10.1016/j.semperi.2023.151791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.
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Affiliation(s)
- Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, University of Sussex, UK.
| | - Judith Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego CA, USA; College of Nursing, University of Rhode Island, Kingston RI, USA
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Wojcik MH, Poduri AH, Holm IA, MacRae CA, Goldstein RD. The fundamental need for unifying phenotypes in sudden unexpected pediatric deaths. Front Med (Lausanne) 2023; 10:1166188. [PMID: 37332751 PMCID: PMC10273404 DOI: 10.3389/fmed.2023.1166188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/03/2023] [Indexed: 06/20/2023] Open
Abstract
A definitive, authoritative approach to evaluate the causes of unexpected, and ultimately unexplained, pediatric deaths remains elusive, relegating final conclusions to diagnoses of exclusion in the vast majority of cases. Research into unexplained pediatric deaths has focused primarily on sudden infant deaths (under 1 year of age) and led to the identification of several potential, albeit incompletely understood, contributory factors: nonspecific pathology findings, associations with sleep position and environment that may not be uniformly relevant, and the elucidation of a role for serotonin that is practically difficult to estimate in any individual case. Any assessment of progress in this field must also acknowledge the failure of current approaches to substantially decrease mortality rates in decades. Furthermore, potential commonalities with pediatric deaths across a broader age spectrum have not been widely considered. Recent epilepsy-related observations and genetic findings, identified post-mortem in both infants and children who died suddenly and unexpectedly, suggest a role for more intense and specific phenotyping efforts as well as an expanded role for genetic and genomic evaluation. We therefore present a new approach to reframe the phenotype in sudden unexplained deaths in the pediatric age range, collapsing many distinctions based on arbitrary factors (such as age) that have previously guided research in this area, and discuss its implications for the future of postmortem investigation.
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Affiliation(s)
- Monica H. Wojcik
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Annapurna H. Poduri
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, United States
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ingrid A. Holm
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Calum A. MacRae
- Harvard Medical School, Boston, MA, United States
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Richard D. Goldstein
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
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8
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Brownstein CA, Douard E, Haynes RL, Koh HY, Haghighi A, Keywan C, Martin B, Alexandrescu S, Haas EA, Vargas SO, Wojcik MH, Jacquemont S, Poduri AH, Goldstein RD, Holm IA. Copy Number Variation and Structural Genomic Findings in 116 Cases of Sudden Unexplained Death between 1 and 28 Months of Age. ADVANCED GENETICS (HOBOKEN, N.J.) 2023; 4:2200012. [PMID: 36910592 PMCID: PMC10000288 DOI: 10.1002/ggn2.202200012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/31/2022] [Indexed: 11/09/2022]
Abstract
In sudden unexplained death in pediatrics (SUDP) the cause of death is unknown despite an autopsy and investigation. The role of copy number variations (CNVs) in SUDP has not been well-studied. Chromosomal microarray (CMA) data are generated for 116 SUDP cases with age at death between 1 and 28 months. CNVs are classified using the American College of Medical Genetics and Genomics guidelines and CNVs in our cohort are compared to an autism spectrum disorder (ASD) cohort, and to a control cohort. Pathogenic CNVs are identified in 5 of 116 cases (4.3%). Variants of uncertain significance (VUS) favoring pathogenic CNVs are identified in 9 cases (7.8%). Several CNVs are associated with neurodevelopmental phenotypes including seizures, ASD, developmental delay, and schizophrenia. The structural variant 47,XXY is identified in two cases (2/69 boys, 2.9%) not previously diagnosed with Klinefelter syndrome. Pathogenicity scores for deletions are significantly elevated in the SUDP cohort versus controls (p = 0.007) and are not significantly different from the ASD cohort. The finding of pathogenic or VUS favoring pathogenic CNVs, or structural variants, in 12.1% of cases, combined with the observation of higher pathogenicity scores for deletions in SUDP versus controls, suggests that CMA should be included in the genetic evaluation of SUDP.
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Progression in Time of Dentate Gyrus Granule Cell Layer Widening due to Excitotoxicity Occurs along In Vivo LTP Reinstatement and Contextual Fear Memory Recovery. Neural Plast 2022; 2022:7432842. [PMID: 36213614 PMCID: PMC9533134 DOI: 10.1155/2022/7432842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/25/2022] [Accepted: 08/04/2022] [Indexed: 11/17/2022] Open
Abstract
The dentate gyrus (DG) is the gateway of sensory information arriving from the perforant pathway (PP) to the hippocampus. The adequate integration of incoming information into the DG is paramount in the execution of hippocampal-dependent cognitive functions. An abnormal DG granule cell layer (GCL) widening due to granule cell dispersion has been reported under hyperexcitation conditions in animal models as well as in patients with mesial temporal lobe epilepsy, but also in patients with no apparent relation to epilepsy. Strikingly, it is unclear whether the presence and severity of GCL widening along time affect synaptic processing arising from the PP and alter the performance in hippocampal-mediated behaviors. To evaluate the above, we injected excitotoxic kainic acid (KA) unilaterally into the DG of mice and analyzed the evolution of GCL widening at 10 and 30 days post injection (dpi), while analyzing if KA-induced GCL widening affected in vivo long-term potentiation (LTP) in the PP-DG pathway, as well as the performance in learning and memory through contextual fear conditioning. Our results show that at 10 dpi, when a subtle GCL widening was observed, LTP induction, as well as contextual fear memory, were impaired. However, at 30 dpi when a pronounced increase in GCL widening was found, LTP induction and contextual fear memory were already reestablished. These results highlight the plastic potential of the DG to recover some of its functions despite a major structural alteration such as abnormal GCL widening.
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Falsaperla R, Consentino MC, Vitaliti G, Marino S, Ruggieri M. Isolated ictal apnea in neonatal age: Clinical features and treatment options. A systematic review. Auton Neurosci 2022; 243:103034. [PMID: 36174277 DOI: 10.1016/j.autneu.2022.103034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/27/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Among autonomic seizures apnea still represent a challenge for physicians, and it might constitute the only isolated sign of neurological disorder. The aim of this review is to describe ictal apnea (IA) and its treatment options. METHODS MeSH and keywords were combined: "neonatal seizures", "ictal neonatal apnea", "apneic seizures". All identified papers were screened for neonatal seizures titles and abstracts; case reports describing patients with IA as an isolated manifestation of neonatal seizures were included. RESULTS Eight studies including a total of 13 patients were identified. Among 13 patients, 9 were full-term and 4 were preterm neonates. All patients developed IA within twenty-one days from birth. Etiologies of seizures included: temporal lobe hemorrhage (3 pt), occipital stroke (1 pt), hypoxic-ischemic encephalopathy (HIE) (1 pt), parasagittal injury (1 pt), 18 trisomy (2 pt). Five patients showed no structural CNS alterations. Ten patients had the ictal focus localized in the temporal lobe; the occipital lobe was the second most involved site. Phenobarbital was administered in 76 % of cases with IA (10 pt), and showed efficacy in 74 % of them; 2 required a second anti-epileptic drug (AED) to reach seizure control. Levetiracetam was given to 11 % (2 pt) successfully. Only one was treated with midazolam and one did not require any anticonvulsant. CONCLUSIONS Not homogeneous data and paucity of isolated IA currently reported in literature limits agreement about definition, management and treatment of entity, however an ever-growing attention is needed, and EEG/aEEG, despite their possible controversies in the diagnosis, should be performed to investigate unexplained forms of apnea.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit [NICU], AOU "Rodolico - San Marco", PO "San Marco", University of Catania, Catania, Italy; Unit of Pediatrics and Pediatric Emergency, AOU "Rodolico - San Marco", PO "San Marco", University of Catania, Catania, Italy
| | - Maria Chiara Consentino
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, Unit of Rare Diseases of the Nervous System in Childhood, University of Catania, Catania, Italy
| | - Giovanna Vitaliti
- Unit of Pediatrics, Department of Medical Sciences, Section of Pediatrics, University Hospital Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Silvia Marino
- Unit of Pediatrics and Pediatric Emergency, AOU "Rodolico - San Marco", PO "San Marco", University of Catania, Catania, Italy.
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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Leifeld J, Förster E, Reiss G, Hamad MIK. Considering the Role of Extracellular Matrix Molecules, in Particular Reelin, in Granule Cell Dispersion Related to Temporal Lobe Epilepsy. Front Cell Dev Biol 2022; 10:917575. [PMID: 35733853 PMCID: PMC9207388 DOI: 10.3389/fcell.2022.917575] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
The extracellular matrix (ECM) of the nervous system can be considered as a dynamically adaptable compartment between neuronal cells, in particular neurons and glial cells, that participates in physiological functions of the nervous system. It is mainly composed of carbohydrates and proteins that are secreted by the different kinds of cell types found in the nervous system, in particular neurons and glial cells, but also other cell types, such as pericytes of capillaries, ependymocytes and meningeal cells. ECM molecules participate in developmental processes, synaptic plasticity, neurodegeneration and regenerative processes. As an example, the ECM of the hippocampal formation is involved in degenerative and adaptive processes related to epilepsy. The role of various components of the ECM has been explored extensively. In particular, the ECM protein reelin, well known for orchestrating the formation of neuronal layer formation in the cerebral cortex, is also considered as a player involved in the occurrence of postnatal granule cell dispersion (GCD), a morphologically peculiar feature frequently observed in hippocampal tissue from epileptic patients. Possible causes and consequences of GCD have been studied in various in vivo and in vitro models. The present review discusses different interpretations of GCD and different views on the role of ECM protein reelin in the formation of this morphological peculiarity.
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Affiliation(s)
- Jennifer Leifeld
- Department of Neuroanatomy and Molecular Brain Research, Medical Faculty, Ruhr University Bochum, Bochum, Germany
- Department of Biochemistry I—Receptor Biochemistry, Faculty of Chemistry and Biochemistry, Ruhr University Bochum, Bochum, Germany
- *Correspondence: Jennifer Leifeld, ; Eckart Förster,
| | - Eckart Förster
- Department of Neuroanatomy and Molecular Brain Research, Medical Faculty, Ruhr University Bochum, Bochum, Germany
- *Correspondence: Jennifer Leifeld, ; Eckart Förster,
| | - Gebhard Reiss
- Institute for Anatomy and Clinical Morphology, School of Medicine, Faculty of Health, Witten/ Herdecke University, Witten, Germany
| | - Mohammad I. K. Hamad
- Institute for Anatomy and Clinical Morphology, School of Medicine, Faculty of Health, Witten/ Herdecke University, Witten, Germany
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Koh HY, Haghighi A, Keywan C, Alexandrescu S, Plews-Ogan E, Haas EA, Brownstein CA, Vargas SO, Haynes RL, Berry GT, Holm IA, Poduri AH, Goldstein RD. Genetic Determinants of Sudden Unexpected Death in Pediatrics. Genet Med 2022; 24:839-850. [PMID: 35027292 PMCID: PMC9164313 DOI: 10.1016/j.gim.2021.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE This study aimed to evaluate genetic contributions to sudden unexpected death in pediatrics (SUDP). METHODS We phenotyped and performed exome sequencing for 352 SUDP cases. We analyzed variants in 294 "SUDP genes" with mechanisms plausibly related to sudden death. In a subset of 73 cases with parental data (trios), we performed exome-wide analyses and conducted cohort-wide burden analyses. RESULTS In total, we identified likely contributory variants in 37 of 352 probands (11%). Analysis of SUDP genes identified pathogenic/likely pathogenic variants in 12 of 352 cases (SCN1A, DEPDC5 [2], GABRG2, SCN5A [2], TTN [2], MYBPC3, PLN, TNNI3, and PDHA1) and variants of unknown significance-favor-pathogenic in 17 of 352 cases. Exome-wide analyses of the 73 cases with family data additionally identified 4 de novo pathogenic/likely pathogenic variants (SCN1A [2], ANKRD1, and BRPF1) and 4 de novo variants of unknown significance-favor-pathogenic. Comparing cases with controls, we demonstrated an excess burden of rare damaging SUDP gene variants (odds ratio, 2.94; 95% confidence interval, 2.37-4.21) and of exome-wide de novo variants in the subset of 73 with trio data (odds ratio, 3.13; 95% confidence interval, 1.91-5.16). CONCLUSION We provide strong evidence for a role of genetic factors in SUDP, involving both candidate genes and novel genes for SUDP and expanding phenotypes of disease genes not previously associated with sudden death.
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Affiliation(s)
- Hyun Yong Koh
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA; Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA; Division of Genetics and Genomics, Department of Pediatrics and Manton Center for Orphan Diseases Research, Boston Children's Hospital, MA
| | - Alireza Haghighi
- Department of Genetics, Harvard Medical School, Boston, MA; Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA
| | - Christine Keywan
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA
| | - Sanda Alexandrescu
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Departments of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Erin Plews-Ogan
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Elisabeth A Haas
- Department of Research, Rady Children's Hospital-San Diego, San Diego, CA
| | - Catherine A Brownstein
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Division of Genetics and Genomics, Department of Pediatrics and Manton Center for Orphan Diseases Research, Boston Children's Hospital, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sara O Vargas
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Departments of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Robin L Haynes
- Departments of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Gerard T Berry
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Division of Genetics and Genomics, Department of Pediatrics and Manton Center for Orphan Diseases Research, Boston Children's Hospital, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ingrid A Holm
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Division of Genetics and Genomics, Department of Pediatrics and Manton Center for Orphan Diseases Research, Boston Children's Hospital, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Annapurna H Poduri
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA; Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Department of Neurology, Harvard Medical School, Boston, MA
| | - Richard D Goldstein
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
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Chambers JK, Iwasaki S, Imamoto S, Nakamoto Y, Uchida K. A case of feline temporal lobe epilepsy with hippocampal sclerosis and dentate gyrus malformation. J Vet Med Sci 2022; 84:634-637. [PMID: 35342145 PMCID: PMC9177400 DOI: 10.1292/jvms.22-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A two-months-old, male, mixed breed cat presented with epileptic seizures. The cat was diagnosed with drug-resistant epilepsy, and died at 3-years of age. No gross lesion was found at
necropsy. Histopathologically, the dentate gyrus granule cell layer of the hippocampus was irregularly arranged. Granule cells were dispersed and ectopic cells were sporadically observed in
the molecular layer. The granule cells had an enlarged cytoplasm and swollen nucleus. Immunohistochemistry for NeuN and GFAP confirmed severe neuronal loss and mild gliosis in CA1.
Binucleation and ischemic change were observed in the remaining pyramidal cells. This report describes a case of feline temporal lobe epilepsy and hippocampal sclerosis associated with
dentate gyrus malformation.
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Affiliation(s)
- James K Chambers
- Laboratory of Veterinary Pathology, Graduate School of Agricultural and Life Sciences, The University of Tokyo
| | - Shinya Iwasaki
- Laboratory of Veterinary Pathology, Graduate School of Agricultural and Life Sciences, The University of Tokyo
| | | | - Yuya Nakamoto
- Neuro Vets Animal Neurology Clinic.,Veterinary Medical Center, Osaka Prefecture University
| | - Kazuyuki Uchida
- Laboratory of Veterinary Pathology, Graduate School of Agricultural and Life Sciences, The University of Tokyo
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14
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Teran FA, Bravo E, Richerson GB. Sudden unexpected death in epilepsy: Respiratory mechanisms. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:153-176. [PMID: 36031303 PMCID: PMC10191258 DOI: 10.1016/b978-0-323-91532-8.00012-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Epilepsy is one of the most common chronic neurologic diseases, with a prevalence of 1% in the US population. Many people with epilepsy live normal lives, but are at risk of sudden unexpected death in epilepsy (SUDEP). This mysterious comorbidity of epilepsy causes premature death in 17%-50% of those with epilepsy. Most SUDEP occurs after a generalized seizure, and patients are typically found in bed in the prone position. Until recently, it was thought that SUDEP was due to cardiovascular failure, but patients who died while being monitored in hospital epilepsy units revealed that most SUDEP is due to postictal central apnea. Some cases may occur when seizures invade the amygdala and activate projections to the brainstem. Evidence suggests that the pathophysiology is linked to defects in the serotonin system and central CO2 chemoreception, and that there is considerable overlap with mechanisms thought to be involved in sudden infant death syndrome (SIDS). Future work is needed to identify biomarkers for patients at highest risk, improve ascertainment, develop methods to alert caregivers when SUDEP is imminent, and find effective approaches to prevent these fatal events.
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Affiliation(s)
- Frida A Teran
- Department of Neurology, University of Iowa, Iowa City, IA, United States; Medical Scientist Training Program, University of Iowa, Iowa City, IA, United States.
| | - Eduardo Bravo
- Department of Neurology, University of Iowa, Iowa City, IA, United States
| | - George B Richerson
- Department of Neurology, University of Iowa, Iowa City, IA, United States; Department of Molecular Physiology & Biophysics, University of Iowa, Iowa City, IA, United States
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15
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Despotovski V, Vivekanandarajah A, Waters KA, Machaalani R. Early Postnatal Exposure to Intermittent Hypercapnic Hypoxia (IHH), but Not Nicotine, Decreases Reelin in the Young Piglet Hippocampus. Neurotox Res 2022; 40:1859-1868. [PMID: 36322363 PMCID: PMC9797456 DOI: 10.1007/s12640-022-00598-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
This study evaluated the expression of reelin, an extracellular protein involved in lamination and migration of neurons, in the hippocampus of young piglets, and quantified to examine the following: (i) baseline levels within layers of the hippocampus and dentate gyrus (DG); (ii) differences between ventral and dorsal hippocampi; and (iii) changes attributable to postnatal exposure to continuous nicotine for 12 days, or intermittent hypercapnic hypoxia (IHH), with further analysis according to duration of IHH (1 vs 4 days). Additionally, we analysed whether any exposure altered DG morphology and whether it is related to altered reelin expression. Reelin was visualised via immunohistochemistry, and the number of positive reelin cells/mm2 was measured in the CA4/Hilus, layers of the DG, and the CA1. The dorsal DG had significantly more reelin within the subgranular zone compared to the ventral DG (p < 0.01). There was no difference in reelin between nicotine (n = 5) and controls (n = 5). IHH exposed piglets (n = 10) had significantly lowered reelin in the CA1 (p = 0.05), specifically the stratum pyramidale (p = 0.04) and the hippocampal fissure (p = 0.02), compared to their controls (n = 7); the duration of IHH had no effect. No exposure was associated with an alteration in DG morphology. This study shows that postnatal IHH exposure decreased reelin expression in the developing piglet hippocampal CA1, suggesting that IHH may result in altered neuronal migration.
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Affiliation(s)
- Vanessa Despotovski
- grid.1013.30000 0004 1936 834XDiscipline of Science, Life and Environmental Science, The University of Sydney, Camperdown, NSW Australia
| | - Arunnjah Vivekanandarajah
- grid.1013.30000 0004 1936 834XDiscipline of Medicine, Central Clinical School, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia
| | - Karen A. Waters
- grid.1013.30000 0004 1936 834XDiscipline of Medicine, Central Clinical School, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia ,grid.1013.30000 0004 1936 834XDiscipline of Child and Adolescent Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia
| | - Rita Machaalani
- grid.1013.30000 0004 1936 834XDiscipline of Medicine, Central Clinical School, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia ,grid.1013.30000 0004 1936 834XDiscipline of Child and Adolescent Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia
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16
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Haynes RL, Kinney HC, Haas EA, Duncan JR, Riehs M, Trachtenberg F, Armstrong DD, Alexandrescu S, Cryan JB, Hefti MM, Krous HF, Goldstein RD, Sleeper LA. Medullary Serotonergic Binding Deficits and Hippocampal Abnormalities in Sudden Infant Death Syndrome: One or Two Entities? Front Pediatr 2021; 9:762017. [PMID: 34993162 PMCID: PMC8724302 DOI: 10.3389/fped.2021.762017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/17/2021] [Indexed: 11/27/2022] Open
Abstract
Sudden infant death syndrome (SIDS) is understood as a syndrome that presents with the common phenotype of sudden death but involves heterogenous biological causes. Many pathological findings have been consistently reported in SIDS, notably in areas of the brain known to play a role in autonomic control and arousal. Our laboratory has reported abnormalities in SIDS cases in medullary serotonin (5-HT) receptor 1A and within the dentate gyrus of the hippocampus. Unknown, however, is whether the medullary and hippocampal abnormalities coexist in the same SIDS cases, supporting a biological relationship of one abnormality with the other. In this study, we begin with an analysis of medullary 5-HT1A binding, as determined by receptor ligand autoradiography, in a combined cohort of published and unpublished SIDS (n = 86) and control (n = 22) cases. We report 5-HT1A binding abnormalities consistent with previously reported data, including lower age-adjusted mean binding in SIDS and age vs. diagnosis interactions. Utilizing this combined cohort of cases, we identified 41 SIDS cases with overlapping medullary 5-HT1A binding data and hippocampal assessment and statistically addressed the relationship between abnormalities at each site. Within this SIDS analytic cohort, we defined abnormal (low) medullary 5-HT1A binding as within the lowest quartile of binding adjusted for age and we examined three specific hippocampal findings previously identified as significantly more prevalent in SIDS compared to controls (granular cell bilamination, clusters of immature cells in the subgranular layer, and single ectopic cells in the molecular layer of the dentate gyrus). Our data did not find a strong statistical relationship between low medullary 5-HT1A binding and the presence of any of the hippocampal abnormalities examined. It did, however, identify a subset of SIDS (~25%) with both low medullary 5-HT1A binding and hippocampal abnormalities. The subset of SIDS cases with both low medullary 5-HT1A binding and single ectopic cells in the molecular layer was associated with prenatal smoking (p = 0.02), suggesting a role for the exposure in development of the two abnormalities. Overall, our data present novel information on the relationship between neuropathogical abnormalities in SIDS and support the heterogenous nature and overall complexity of SIDS pathogenesis.
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Affiliation(s)
- Robin L. Haynes
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Hannah C. Kinney
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Elisabeth A. Haas
- Department of Research, Rady's Children's Hospital, San Diego, CA, United States
| | | | - Molly Riehs
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | | | - Dawna D. Armstrong
- Department of Pathology (Emeritus), Baylor College of Medicine, Houston, TX, United States
| | - Sanda Alexandrescu
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jane B. Cryan
- Department of Neuropathology, Children's Health Ireland and Beaumont Hospitals, Dublin, Ireland
| | - Marco M. Hefti
- Department of Pathology, University of Iowa, Iowa City, IA, United States
| | - Henry F. Krous
- Department of Pathology (Emeritus), Rady Children's Hospital, San Diego, CA, United States
- Department of Pediatrics (Emeritus), University of California, San Diego, San Diego, CA, United States
| | - Richard D. Goldstein
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Robert's Program on Sudden Unexpected Death in Pediatrics, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
| | - Lynn A. Sleeper
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
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17
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Machaalani R, Vivekanandarajah A, Despotovski V, Rodriguez M, Waters KA. Morphology of the Dentate Gyrus in a Large Cohort of Sudden Infant Deaths-Interrelation Between Features but Not Diagnosis. J Neuropathol Exp Neurol 2021; 81:61-75. [PMID: 34865047 DOI: 10.1093/jnen/nlab119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Morphological differences in the dentate gyrus (DG) have been reported in sudden unexpected deaths in infancy (SUDI), with the feature of focal granule cell (GC) bilamination (FGCB) reported as increased in unexplained SUDI, including sudden infant death syndrome (SIDS), compared with explained SUDI (eSUDI). However, it remains to be determined how these morphologies relate to each other and their extent along the anteroposterior length. This retrospective study evaluated the prevalence of FGCB, single or clustered ectopic GCs, granule cell dispersion (GCD), heterotopia, hyperconvolution, gaps, thinning, blood vessel dissection (BVD), and cuffing (BV cuffing), in an Australian SUDI cohort, and compared the prevalence of these features in eSUDI and unexplained SUDI. We analyzed 850 formalin-fixed paraffin-embedded serial and subserial sections of the hippocampus at the level of the lateral geniculate nucleus from 90 infants, and identified GCD in 97% of infants, single ectopic cells, hyperconvolution, thinning, and BVD in 60%-80%, heterotopia in 36%, gaps, clusters of ectopic cells and BV cuffing in 9%-15%, and FGCB in 18%. These features are clustered within 3-5 serial sections. The presence of FGCB correlated with single ectopic GCs and hyperconvolution. There were no differences in the prevalence of these features between unexplained SUDI (n = 74) and eSUDI (n = 16). Our findings highlight that DG morphological features are highly localized, extending 14-35 µm at their focal location(s) along the anteroposterior length. Consequently, multiple sections along the longitudinal extent are required to identify them. No feature differentiated SUDI from eSUDI in our cohort, thus we cannot conclude that any of these features are abnormal and it remains to be determined their functional significance.
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Affiliation(s)
- Rita Machaalani
- From the Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, AV, VD, KAW); Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, KAW); and Discipline of Pathology, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia (MR)
| | - Arunnjah Vivekanandarajah
- From the Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, AV, VD, KAW); Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, KAW); and Discipline of Pathology, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia (MR)
| | - Vanessa Despotovski
- From the Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, AV, VD, KAW); Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, KAW); and Discipline of Pathology, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia (MR)
| | - Michael Rodriguez
- From the Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, AV, VD, KAW); Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, KAW); and Discipline of Pathology, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia (MR)
| | - Karen A Waters
- From the Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, AV, VD, KAW); Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia (RM, KAW); and Discipline of Pathology, Faculty of Medicine and Health, School of Medical Sciences, The University of Sydney, Sydney, New South Wales, Australia (MR)
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18
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Morris A, Elliott E, Jeffery H. Paediatrician experience of management of Sudden Unexpected Death in Infancy. J Forensic Leg Med 2021; 84:102268. [PMID: 34768190 DOI: 10.1016/j.jflm.2021.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/20/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
Sudden unexpected death in infancy (SUDI) requires a thorough process of inquiry including a detailed history, death scene investigation and autopsy by appropriate and informed health professionals to identify aetiology. Paediatricians are required to conduct the medical, social and family history as well as provide support to the family for the approximately 45 deaths each year in New South Wales (NSW). The aim of this study is describe paediatricians' experience in conducting SUDI assessments with reference to current NSW Health policy and identify barriers to its implementation. METHODS Paediatricians in NSW who participate in the Australian Paediatric Surveillance Unit (APSU) were invited to complete a questionnaire requesting information about their knowledge and confidence in managing an infant presenting with SUDI, awareness and use of the NSW Health Policy Directive, and their own recommendations for management. A second questionnaire was completed by paediatricians who had attended a SUDI in the previous five years. RESULTS The first survey was completed by 234/524 (44%) NSW paediatricians. Half the respondents (118/234) were aware of the SUDI Policy Directive and of those 72/118 (61%) had read it. Few paediatricians (63/234) 27% had received education on the Policy Directive or about SUDI management 55/234 (24%). The second survey was completed by 33/36 (92%) who had attended a SUDI, of whom 29% had not used the history protocol within the Policy Directive. CONCLUSION Lack of awareness, perceived problems with the current Policy, and limited confidence suggests the model in NSW needs revision to meet international recommendations for best management and diagnosis and also supportive and preventive practices for parents.
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Affiliation(s)
- Anne Morris
- The University of Sydney, Faculty of Medicine and Health, The Sydney Children's Hospitals Network, Westmead, Sydney, New South Wales, Australia.
| | - Elizabeth Elliott
- The University of Sydney, Faculty of Medicine and Health, The Sydney Children's Hospitals Network, Westmead, Sydney, New South Wales, Australia
| | - Heather Jeffery
- Sydney School Public Health & Previously Clinical Academic Neonatologist, Royal Prince Alfred Hospital, Sydney, Australia
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Patodia S, Somani A, Thom M. Review: Neuropathology findings in autonomic brain regions in SUDEP and future research directions. Auton Neurosci 2021; 235:102862. [PMID: 34411885 PMCID: PMC8455454 DOI: 10.1016/j.autneu.2021.102862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/16/2021] [Accepted: 07/24/2021] [Indexed: 12/21/2022]
Abstract
Autonomic dysfunction is implicated from clinical, neuroimaging and experimental studies in sudden and unexpected death in epilepsy (SUDEP). Neuropathological analysis in SUDEP series enable exploration of acquired, seizure-related cellular adaptations in autonomic and brainstem autonomic centres of relevance to dysfunction in the peri-ictal period. Alterations in SUDEP compared to control groups have been identified in the ventrolateral medulla, amygdala, hippocampus and central autonomic regions. These involve neuropeptidergic, serotonergic and adenosine systems, as well as specific regional astroglial and microglial populations, as potential neuronal modulators, orchestrating autonomic dysfunction. Future research studies need to extend to clinically and genetically characterized epilepsies, to explore if common or distinct pathways of autonomic dysfunction mediate SUDEP. The ultimate objective of SUDEP research is the identification of disease biomarkers for at risk patients, to improve post-mortem recognition and disease categorisation, but ultimately, for exposing potential treatment targets of pharmacologically modifiable and reversible cellular alterations.
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Affiliation(s)
- Smriti Patodia
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Alyma Somani
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Maria Thom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK.
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20
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Leitner DF, Faustin A, Verducci C, Friedman D, William C, Devore S, Wisniewski T, Devinsky O. Neuropathology in the North American sudden unexpected death in epilepsy registry. Brain Commun 2021; 3:fcab192. [PMID: 34514397 PMCID: PMC8417454 DOI: 10.1093/braincomms/fcab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/12/2022] Open
Abstract
Sudden unexpected death in epilepsy is the leading category of epilepsy-related death and the underlying mechanisms are incompletely understood. Risk factors can include a recent history and high frequency of generalized tonic-clonic seizures, which can depress brain activity postictally, impairing respiration, arousal and protective reflexes. Neuropathological findings in sudden unexpected death in epilepsy cases parallel those in other epilepsy patients, with no implication of novel structures or mechanisms in seizure-related deaths. Few large studies have comprehensively reviewed whole brain examination of such patients. We evaluated 92 North American Sudden unexpected death in epilepsy Registry cases with whole brain neuropathological examination by board-certified neuropathologists blinded to the adjudicated cause of death, with an average of 16 brain regions examined per case. The 92 cases included 61 sudden unexpected death in epilepsy (40 definite, 9 definite plus, 6 probable, 6 possible) and 31 people with epilepsy controls who died from other causes. The mean age at death was 34.4 years and 65.2% (60/92) were male. The average age of death was younger for sudden unexpected death in epilepsy cases than for epilepsy controls (30.0 versus 39.6 years; P = 0.006), and there was no difference in sex distribution respectively (67.3% male versus 64.5%, P = 0.8). Among sudden unexpected death in epilepsy cases, earlier age of epilepsy onset positively correlated with a younger age at death (P = 0.0005) and negatively correlated with epilepsy duration (P = 0.001). Neuropathological findings were identified in 83.7% of the cases in our cohort. The most common findings were dentate gyrus dysgenesis (sudden unexpected death in epilepsy 50.9%, epilepsy controls 54.8%) and focal cortical dysplasia (FCD) (sudden unexpected death in epilepsy 41.8%, epilepsy controls 29.0%). The neuropathological findings in sudden unexpected death in epilepsy paralleled those in epilepsy controls, including the frequency of total neuropathological findings as well as the specific findings in the dentate gyrus, findings pertaining to neurodevelopment (e.g. FCD, heterotopias) and findings in the brainstem (e.g. medullary arcuate or olivary dysgenesis). Thus, like prior studies, we found no neuropathological findings that were more common in sudden unexpected death in epilepsy cases. Future neuropathological studies evaluating larger sudden unexpected death in epilepsy and control cohorts would benefit from inclusion of different epilepsy syndromes with detailed phenotypic information, consensus among pathologists particularly for more subjective findings where observations can be inconsistent, and molecular approaches to identify markers of sudden unexpected death in epilepsy risk or pathogenesis.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Arline Faustin
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Chloe Verducci
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Christopher William
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
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21
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Leitner DF, McGuone D, William C, Faustin A, Askenazi M, Snuderl M, Guzzetta M, Jarrell HS, Maloney K, Reichard R, Smith C, Weedn V, Wisniewski T, Gould L, Devinsky O. Blinded review of hippocampal neuropathology in sudden unexplained death in childhood reveals inconsistent observations and similarities to explained paediatric deaths. Neuropathol Appl Neurobiol 2021; 48:e12746. [PMID: 34164845 DOI: 10.1111/nan.12746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/19/2021] [Indexed: 12/29/2022]
Abstract
AIMS Hippocampal findings are implicated in the pathogenesis of sudden unexplained death in childhood (SUDC), although some studies have identified similar findings in sudden explained death in childhood (SEDC) cases. We blindly reviewed hippocampal histology in SUDC and SEDC controls. METHODS Hippocampal haematoxylin and eosin (H&E) slides (n = 67; 36 SUDC, 31 controls) from clinical and forensic collaborators were evaluated by nine blinded reviewers: three board-certified forensic pathologists, three neuropathologists and three dual-certified neuropathologists/forensic pathologists. RESULTS Among nine reviewers, about 50% of hippocampal sections were rated as abnormal (52.5% SUDC, 53.0% controls), with no difference by cause of death (COD) (p = 0.16) or febrile seizure history (p = 0.90). There was little agreement among nine reviewers on whether a slide was within normal range (Fleiss' κ = 0.014, p = 0.47). Within reviewer groups, there were no findings more frequent in SUDC compared with controls, with variability in pyramidal neuron and dentate gyrus findings. Across reviewer groups, there was concordance for bilamination and granule cell loss. Neither SUDC (51.2%) nor control (55.9%) slides were considered contributory to determining COD (p = 0.41). CONCLUSIONS The lack of an association of hippocampal findings in SUDC and controls, as well as inconsistency of observations by multiple blinded reviewers, indicates discrepancy with previous studies and an inability to reliably identify hippocampal maldevelopment associated with sudden death (HMASD). These findings underscore a need for larger studies to standardise evaluation of hippocampal findings, identifying the range of normal variation and changes unrelated to SUDC or febrile seizures. Molecular studies may help identify novel immunohistological markers that inform on COD.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA
| | - Christopher William
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Arline Faustin
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
| | | | - Matija Snuderl
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Melissa Guzzetta
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Heather S Jarrell
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,New Mexico Office of the Medical Investigator, Albuquerque, New Mexico, USA
| | - Katherine Maloney
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,New York Department of Health, Erie County Medical Examiner's Office, Buffalo, New York, USA
| | - Ross Reichard
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin Smith
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Academic Department of Neuropathology, University of Edinburgh, Edinburgh, UK
| | - Victor Weedn
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Maryland Department of Health, Office of the Chief Medical Examiner, Baltimore, Maryland, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA.,Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Psychiatry, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Laura Gould
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Sudden Unexplained Death in Childhood Foundation, Roseland, New Jersey, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
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22
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Luijerink LLM, Vivekanandarajah A, Waters KA, Machaalani R. The α7 and β2 nicotinic acetylcholine receptor subunits regulate apoptosis in the infant hippocampus, and in sudden infant death syndrome (SIDS). Apoptosis 2021; 25:574-589. [PMID: 32577853 DOI: 10.1007/s10495-020-01618-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Apoptosis is increased in the hippocampus of infants who died of sudden infant death syndrome (SIDS), yet it is not known via which mechanism this has occurred. Following existing support for a role of the α7 and β2 nicotinic acetylcholine receptor (nAChR) subunits in apoptotic regulation, we aimed to determine whether these subunits are altered in the SIDS hippocampus and if they are correlated with cell death markers of active caspase-3 (Casp-3) and TUNEL. Further analyses were run according to the presence of major SIDS risk factors related to hypoxia (bed-sharing and prone sleeping), infection (presence of an upper respiratory tract infection (URTI)), cigarette smoke exposure and gender. Immunohistochemical expression of the markers was studied in 4 regions of the hippocampus (Cornu Ammonis (CA)1, CA2, CA3, CA4) and subiculum amongst 52 infants (aged 1-7 months) who died suddenly and unexpectedly (SUDI) and for whom the cause of death was explained (eSUDI; n = 9), or not and characterised as SIDS I (n = 8) and SIDS II (n = 35) according to the San Diego diagnostic criteria. Results showed that SIDS II infants had widespread increases in TUNEL compared with eSUDI and SIDS I infants, as well as increased α7 and Casp-3 in CA2 compared to eSUDI infants, although these changes were predominant amongst infants who did not bed-share. Cigarette smoke exposure had minimal effects on the markers, while an URTI was associated with changes in all markers (after accounting for bed-sharing). Our findings support the role of nAChRs in regulating apoptosis in the SIDS hippocampus, and highlight the need for separate analysis according to risk factors.
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Affiliation(s)
- L L M Luijerink
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Medical Foundation Building K25, Sydney, NSW, 2006, Australia
| | - A Vivekanandarajah
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Medical Foundation Building K25, Sydney, NSW, 2006, Australia
| | - K A Waters
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Medical Foundation Building K25, Sydney, NSW, 2006, Australia.,The Children's Hospital at Westmead, Westmead, NSW, 2146, Australia
| | - R Machaalani
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Medical Foundation Building K25, Sydney, NSW, 2006, Australia. .,The Children's Hospital at Westmead, Westmead, NSW, 2146, Australia.
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23
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Eidahl JML, Stray-Pedersen A, Rognum TO, Opdal SH. Aquaporin 4 expression in the hippocampus in sudden infant death syndrome and sudden unexplained death in childhood. J Chem Neuroanat 2021; 115:101962. [PMID: 33945852 DOI: 10.1016/j.jchemneu.2021.101962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022]
Abstract
Aquaporin 4 (AQP4) is the main membrane water channel in the brain involved in regulating water homeostasis. The water distribution in neural tissue is often dysregulated after hypoxic neural injury. Previous research has indicated that victims of sudden infant death syndrome (SIDS) and sudden unexplained death in childhood (SUDC) have an underlying brain dysfunction that impairs their critical arousal response to hypoxic stress during sleep. The aim of this study was to determine the expression levels of AQP4 in the hippocampus in SIDS/SUDC cases and controls, and compare the findings with AQP4 genotypes that previously have been shown to be associated with SIDS. Immunochemical staining and morphometry were used to evaluate the density of AQP4-positive astrocytes in 30 SIDS/SUDC cases and 26 controls. AQP4-positive cells were counted in grids covering three layers in the hippocampus, which revealed that their count in any of the layers did not differ significantly between cases and controls. A decline in AQP4 expression was observed for infants older than 12 weeks. The AQP4 expression was lower in infants and children with the rs2075575 CT/TT genotype than in those with the CC genotype. This study indicates that AQP4 expression may be influenced by both age and genotype in infants. The role of AQP4 in the pathogenesis of SIDS remains to be elucidated.
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Affiliation(s)
- Johanna Marie Lundesgaard Eidahl
- Oslo University Hospital, Division of Laboratory Medicine, Department of Forensic Sciences, Oslo, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
| | - Arne Stray-Pedersen
- Oslo University Hospital, Division of Laboratory Medicine, Department of Forensic Sciences, Oslo, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
| | | | - Siri Hauge Opdal
- Oslo University Hospital, Division of Laboratory Medicine, Department of Forensic Sciences, Oslo, Norway.
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24
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Keywan C, Poduri AH, Goldstein RD, Holm IA. Genetic Factors Underlying Sudden Infant Death Syndrome. APPLICATION OF CLINICAL GENETICS 2021; 14:61-76. [PMID: 33623412 PMCID: PMC7894824 DOI: 10.2147/tacg.s239478] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/24/2021] [Indexed: 12/28/2022]
Abstract
Sudden Infant Death syndrome (SIDS) is a diagnosis of exclusion. Decades of research have made steady gains in understanding plausible mechanisms of terminal events. Current evidence suggests SIDS includes heterogeneous biological conditions, such as metabolic, cardiac, neurologic, respiratory, and infectious conditions. Here we review genetic studies that address each of these areas in SIDS cases and cohorts, providing a broad view of the genetic underpinnings of this devastating phenomenon. The current literature has established a role for monogenic genetic causes of SIDS mortality in a subset of cases. To expand upon our current knowledge of disease-causing genetic variants in SIDS cohorts and their mechanisms, future genetic studies may employ functional assessments of implicated variants, broader genetic tests, and the inclusion of parental genetic data and family history information.
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Affiliation(s)
- Christine Keywan
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Annapurna H Poduri
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Richard D Goldstein
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Ingrid A Holm
- Robert's Program for Sudden Unexpected Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Genetics and Genomics, Department of Pediatrics, and Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA, USA
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25
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Harowitz J, Crandall L, McGuone D, Devinsky O. Seizure-related deaths in children: The expanding spectrum. Epilepsia 2021; 62:570-582. [PMID: 33586153 PMCID: PMC7986159 DOI: 10.1111/epi.16833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/26/2022]
Abstract
Although seizures are common in children, they are often overlooked as a potential cause of death. Febrile and nonfebrile seizures can be fatal in children with or without an epilepsy diagnosis and may go unrecognized by parents or physicians. Sudden unexpected infant deaths, sudden unexplained death in childhood, and sudden unexpected death in epilepsy share clinical, neuropathological, and genetic features, including male predominance, unwitnessed deaths, death during sleep, discovery in the prone position, hippocampal abnormalities, and variants in genes regulating cardiac and neuronal excitability. Additionally, epidemiological studies reveal that miscarriages are more common among individuals with a personal or family history of epilepsy, suggesting that some fetal losses may result from epileptic factors. The spectrum of seizure-related deaths in pediatrics is wide and underappreciated; accurately estimating this mortality and understanding its mechanism in children is critical to developing effective education and interventions to prevent these tragedies.
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Affiliation(s)
- Jenna Harowitz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA.,SUDC Foundation, Herndon, Virginia, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA
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26
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McGuone D, Crandall LG, Devinsky O. Sudden Unexplained Death in Childhood: A Neuropathology Review. Front Neurol 2020; 11:582051. [PMID: 33178125 PMCID: PMC7596260 DOI: 10.3389/fneur.2020.582051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Sudden Unexplained Death in Childhood (SUDC) is the unexpected death of a child over age 12 months that remains unexplained after a thorough case investigation, including review of the child's medical history, circumstances of death, a complete autopsy and ancillary testing (1). First defined in 2005, SUDC cases are more often male, with death occurring during a sleep period, being found prone, peak winter incidence, associated with febrile seizure history in ~28% of cases and mild pathologic changes insufficient to explain the death (1, 2). There has been little progress in understanding the causes of SUDC and no progress in prevention. Despite reductions in sudden unexpected infant death (SUID) and other causes of mortality in childhood, the rate of SUDC has increased during the past two decades (3-5). In Ireland, SUID deaths were cut in half from 1994 to 2008 while SUDC deaths more than doubled (4). Surveillance issues, including lack of standardized certification practices, affect our understanding of the true magnitude of unexplained child deaths. Mechanisms underlying SUDC, like SUID, remain largely speculative. Limited and inconsistent evidence implicates abnormalities in brainstem autonomic and serotonergic nuclei, critical for arousal, cardiorespiratory control, and reflex responses to life-threatening hypoxia or hypercarbia in sleep (6). Abnormalities in medullary serotonergic neurons and receptors, as well as cardiorespiratory brainstem nuclei occur in some SUID cases, but have never been studied in SUDC. Retrospective, small SUDC studies with non-standardized methodologies most often demonstrate minor hippocampal abnormalities, as well as focal cortical dysplasia and dysgenesis of the brainstem and cerebellum. The significance of these findings to SUDC pathogenesis remains unclear with some investigators and forensic pathologists labeling these findings as normal variants, or potential causes of SUDC. The development of preventive strategies will require a greater understanding of underlying mechanisms.
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Affiliation(s)
- Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Laura G Crandall
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, United States.,SUDC Foundation, Herndon, VA, United States
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, United States
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27
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Ambrose N, Rodriguez M, Waters KA, Machaalani R. Microglia in the human infant brain and factors that affect expression. Brain Behav Immun Health 2020; 7:100117. [PMID: 34589874 PMCID: PMC8474518 DOI: 10.1016/j.bbih.2020.100117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
The present study reports on the microglial populations present in 34 regions of the human infant brain (1-11 months), and whether developmental parameters or extrinsic factors such as cigarette smoke exposure, prone sleeping and an upper respiratory tract infection (URTI) influence their expression. Further, we compare microglia populations amongst three sudden unexpected death in infancy (SUDI) sub-groups: explained SUDI (eSUDI, n = 7), sudden infant death syndrome (SIDS) I (n = 8) and SIDS II (n = 13). Ionised calcium binding adaptor molecule-1 (Iba1) was used to determine the morphology and area covered by microglia in a given brain region. Activation was explored using cluster-of-differentiation factor 68 (CD68) and human leukocyte antigen-DP,DQ,DR (HLA). We found regional heterogeneity in the area covered and activation status of microglia across the infant brain. The hippocampus, basal ganglia, white matter and dentate nucleus of the cerebellum showed larger areas of Iba1, while the brainstem had the smallest. Microglia in regions of the basal ganglia and cortex demonstrated positive correlations with infant developmental parameters, while in nuclei of the rostral medulla, negative correlations between microglia parameters were seen. URTI and cigarette smoke exposure were associated with a reduced microglial area in regions of the hippocampus and cortex (parietal and occipital), respectively. In the context of SIDS, a reduced microglial area was seen in SIDS II and fewer SIDS I infants demonstrated activated phenotypes in the hippocampus. Overall, we identify the distribution of microglia in the infant brain to be heterogenous, and influenced by intrinsic and extrinsic factors, and that the SIDS I group is a useful control group for future research into other infant CNS pathologies.
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Affiliation(s)
- Natalie Ambrose
- Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Michael Rodriguez
- Department of Pathology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Karen A. Waters
- Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
- Discipline of Child and Adolescent Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Rita Machaalani
- Discipline of Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
- Discipline of Child and Adolescent Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
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28
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Rochtus AM, Goldstein RD, Holm IA, Brownstein CA, Pérez‐Palma E, Haynes R, Lal D, Poduri AH. The role of sodium channels in sudden unexpected death in pediatrics. Mol Genet Genomic Med 2020; 8:e1309. [PMID: 32449611 PMCID: PMC7434613 DOI: 10.1002/mgg3.1309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sudden Unexpected Death in Pediatrics (SUDP) is a tragic event, likely caused by the complex interaction of multiple factors. The presence of hippocampal abnormalities in many children with SUDP suggests that epilepsy-related mechanisms may contribute to death, similar to Sudden Unexplained Death in Epilepsy. Because of known associations between the genes SCN1A and SCN5A and sudden death, and shared mechanisms and patterns of expression in genes encoding many voltage-gated sodium channels (VGSCs), we hypothesized that individuals dying from SUDP have pathogenic variants across the entire family of cardiac arrhythmia- and epilepsy-associated VGSC genes. METHODS To address this hypothesis, we evaluated whole-exome sequencing data from infants and children with SUDP for variants in VGSC genes, reviewed the literature for all SUDP-associated variants in VGSCs, applied a novel paralog analysis to all variants, and evaluated all variants according to American College of Medical Genetics and Genomics (ACMG) guidelines. RESULTS In our cohort of 73 cases of SUDP, we assessed 11 variants as pathogenic in SCN1A, SCN1B, and SCN10A, genes with long-standing disease associations, and in SCN3A, SCN4A, and SCN9A, VGSC gene paralogs with more recent disease associations. From the literature, we identified 82 VGSC variants in SUDP cases. Pathogenic variants clustered at conserved amino acid sites intolerant to variation across the VGSC genes, which is unlikely to occur in the general population (p < .0001). For 54% of variants previously reported in literature, we identified conflicting evidence regarding pathogenicity when applying ACMG criteria and modern population data. CONCLUSION We report variants in several VGSC genes in cases with SUDP, involving both arrhythmia- and epilepsy-associated genes. Accurate variant assessment as well as future studies are essential for an improved understanding of the contribution of sodium channel-related variants to SUDP.
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Affiliation(s)
- Anne M. Rochtus
- Department of NeurologyBoston Children's Hospital and Harvard Medical SchoolBostonMAUSA
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Department of PediatricsUniversity of LeuvenLeuvenBelgium
| | - Richard D. Goldstein
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Department of PediatricsBoston Children’s Hospital and Harvard Medical SchoolBostonMAUSA
| | - Ingrid A. Holm
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Department of PediatricsBoston Children’s Hospital and Harvard Medical SchoolBostonMAUSA
- Department of MedicineDivision of Genetics and Genomics and the Manton Center for Orphan Disease ResearchBoston Children's HospitalBostonMAUSA
| | - Catherine A. Brownstein
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Department of PediatricsBoston Children’s Hospital and Harvard Medical SchoolBostonMAUSA
- Department of MedicineDivision of Genetics and Genomics and the Manton Center for Orphan Disease ResearchBoston Children's HospitalBostonMAUSA
| | - Eduardo Pérez‐Palma
- Genomic Medicine InstituteLerner Research InstituteCleveland ClinicClevelandOHUSA
- Cologne Center for GenomicsUniversity of CologneCologneGermany
| | - Robin Haynes
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Department of PathologyBoston Children’s Hospital and Harvard Medical SchoolBostonMAUSA
| | - Dennis Lal
- Genomic Medicine InstituteLerner Research InstituteCleveland ClinicClevelandOHUSA
- Cologne Center for GenomicsUniversity of CologneCologneGermany
- Stanley Center for Psychiatric ResearchBroad Institute of Harvard and MITCambridgeMAUSA
| | - Annapurna H. Poduri
- Department of NeurologyBoston Children's Hospital and Harvard Medical SchoolBostonMAUSA
- Robert’s Program on Sudden Death in PediatricsBoston Children’s HospitalBostonMAUSA
- Stanley Center for Psychiatric ResearchBroad Institute of Harvard and MITCambridgeMAUSA
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29
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Kon FC, Vázquez RZ, Lang A, Cohen MC. Hippocampal abnormalities and seizures: a 16-year single center review of sudden unexpected death in childhood, sudden unexpected death in epilepsy and SIDS. Forensic Sci Med Pathol 2020; 16:423-434. [PMID: 32712908 DOI: 10.1007/s12024-020-00268-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 12/27/2022]
Abstract
Sudden Unexpected Death in Childhood (SUDC) is the unexplained death of children aged between 1 and 18 years old. Hippocampal abnormalities have previously been described in Sudden Unexpected Death in Epilepsy (SUDEP) and it is possible that SUDC shares similar pathogenic mechanisms with SUDEP. Our aim was to determine the prevalence of hippocampal abnormalities, history of seizures and demographic features in our caseload of SUDC, SUDEP and SIDS cases. A review of post-mortem reports from 2003 to 2018 was carried out to identify cases of SUDC, SUDEP and SIDS. Histological evidence of hippocampal abnormalities, patient demographics (age, gender), sleeping position, and past medical history (history of seizures and illness 72 hours prior to death) were recorded. Statistical analysis was performed to compare the three groups. 48 SUDC, 18 SUDEP and 358 SIDS cases were identified. Hippocampal abnormalities associated with temporal lobe epilepsy were found in 44.4% of SUDC cases. 5/15 SUDC cases with a history of seizures demonstrated hippocampal abnormalities. SUDC cases were also more likely to be found prone compared to SIDS cases. In comparison with SIDS, both SUDC and SUDEP cases were more likely to demonstrate hippocampal abnormalities (SUDC: (OR = 9.4, 95% CI: 3.1-29.1, p < 0.001; SUDEP: OR = 35.4, 95% CI: 8.3-151.5, p < 0.001). We found a potential link between hippocampal abnormalities and epileptic seizures in SUDC. A concerted effort should be directed towards consistent sampling and standardized description of the hippocampus and clinical correlation with a history of seizures/epilepsy in postmortem reports.
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Affiliation(s)
- Fu Chuen Kon
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK.,Medical School, University of Sheffield, Sheffield, UK
| | | | - Andrew Lang
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK
| | - Marta C Cohen
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK. .,Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK.
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30
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Roy A, Millen KJ, Kapur RP. Hippocampal granule cell dispersion: a non-specific finding in pediatric patients with no history of seizures. Acta Neuropathol Commun 2020; 8:54. [PMID: 32317027 PMCID: PMC7171777 DOI: 10.1186/s40478-020-00928-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/03/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic epilepsy has been associated with hippocampal abnormalities like neuronal loss, gliosis and granule cell dispersion. The granule cell layer of a normal human hippocampal dentate gyrus is traditionally regarded as a compact neuron-dense layer. Histopathological studies of surgically resected or autopsied hippocampal samples primarily from temporal lobe epilepsy patients, as well as animal models of epilepsy, describe variable patterns of granule cell dispersion including focal cell clusters, broader thick segments, and bilamination or “tram-tracking”. Although most studies have implicated granule cell dispersion as a specific feature of chronic epilepsy, very few “non-seizure” controls were included in these published investigations. Our retrospective survey of 147 cadaveric pediatric human hippocampi identified identical morphological spectra of granule cell dispersion in both normal and seizure-affected brains. Moreover, sections across the entire antero-posterior axis of a control cadaveric hippocampus revealed repetitive occurrence of different morphologies of the granule cell layer – compact, focally disaggregated and bilaminar. The results indicate that granule cell dispersion is within the spectrum of normal variation and not unique to patients with epilepsy. We speculate that sampling bias has been responsible for an erroneous dogma, which we hope to rectify with this investigation.
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31
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McGuone D, Leitner D, William C, Faustin A, Leelatian N, Reichard R, Shepherd TM, Snuderl M, Crandall L, Wisniewski T, Devinsky O. Neuropathologic Changes in Sudden Unexplained Death in Childhood. J Neuropathol Exp Neurol 2020; 79:336-346. [PMID: 31995186 PMCID: PMC7036658 DOI: 10.1093/jnen/nlz136] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/14/2019] [Accepted: 12/10/2019] [Indexed: 12/21/2022] Open
Abstract
Sudden unexplained death in childhood (SUDC) affects children >1-year-old whose cause of death remains unexplained following comprehensive case investigation and is often associated with hippocampal abnormalities. We prospectively performed systematic neuropathologic investigation in 20 SUDC cases, including (i) autopsy data and comprehensive ancillary testing, including molecular studies, (ii) ex vivo 3T MRI and extensive histologic brain samples, and (iii) blinded neuropathology review by 2 board-certified neuropathologists. There were 12 girls and 8 boys; median age at death was 33.3 months. Twelve had a history of febrile seizures, 85% died during apparent sleep and 80% in prone position. Molecular testing possibly explained 3 deaths and identified genetic mutations in TNNI3, RYR2, and multiple chromosomal aberrations. Hippocampal abnormalities most often affected the dentate gyrus (altered thickness, irregular configuration, and focal lack of granule cells), and had highest concordance between reviewers. Findings were identified with similar frequencies in cases with and without molecular findings. Number of seizures did not correlate with hippocampal findings. Hippocampal alterations were the most common finding on histological review but were also found in possibly explained deaths. The significance and specificity of hippocampal findings is unclear as they may result from seizures, contribute to seizure pathogenesis, or be an unrelated phenomenon.
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Affiliation(s)
- Declan McGuone
- From the Department of Pathology, Yale School of Medicine, New haven, Connecticut
| | - Dominique Leitner
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
| | - Christopher William
- Department of Neurology
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York
| | | | - Nalin Leelatian
- From the Department of Pathology, Yale School of Medicine, New haven, Connecticut
| | - Ross Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Matija Snuderl
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
- Sudden Unexplained Death in Childhood Foundation, Cedar Grove, New Jersey
| | - Thomas Wisniewski
- Department of Neurology
- Center for Cognitive Neurology, and Psychiatry, NYU Langone Health and School of Medicine, New York, New York
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
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32
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5-HT neurons and central CO2 chemoreception. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/b978-0-444-64125-0.00021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Inconsistent classification of unexplained sudden deaths in infants and children hinders surveillance, prevention and research: recommendations from The 3rd International Congress on Sudden Infant and Child Death. Forensic Sci Med Pathol 2019; 15:622-628. [PMID: 31502215 PMCID: PMC6872710 DOI: 10.1007/s12024-019-00156-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2019] [Indexed: 01/26/2023]
Abstract
This report details the proceedings and conclusions from the 3rd International Congress on Unexplained Deaths in Infants and Children, held November 26–27, 2018 at the Radcliffe Institute at Harvard University. The Congress was motivated by the increasing rejection of the diagnosis Sudden Infant Death Syndrome (SIDS) in the medical examiner community, leading to falsely depressed reported SIDS rates and undermining the validity and reliability of the diagnosis, which remains a leading cause of infant and child mortality. We describe the diagnostic shift away from SIDS and the practical issues contributing to it. The Congress was attended by major figures and opinion leaders in this area from countries significantly engaged in this problem. Four categories (International Classification of Diseases (ICD)-11 categories of MH11, MH12, MH14, PB00-PB0Z) were recommended for classification, and explicit definitions and guidance were provided for death certifiers. SIDS was reframed as unexplained sudden death in infancy or SIDS/MH11 to emphasize that either term signifies the lack of explanation following a rigorous investigation. A distinct category for children over the age of 1 was recommended (MH12). Definitions and exclusions were provided for the alternative categories of accidental asphyxia and undetermined. As recommended, unexplained sudden death in infancy or SIDS on a death certificate will code a unique, trackable entity, accurately reflecting the inability to determine a definitive explanation, while satisfying surveillance needs and reliable identification for research efforts. The conclusions will be submitted to the World Health Organization for inclusion in the upcoming ICD-11.
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Somani A, Zborovschi AB, Liu Y, Patodia S, Michalak Z, Sisodiya SM, Thom M. Hippocampal morphometry in sudden and unexpected death in epilepsy. Neurology 2019; 93:e804-e814. [PMID: 31345959 DOI: 10.1212/wnl.0000000000007969] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine hippocampal morphometric measures, including granule cell dispersion and features of malrotation, as potential biomarkers for sudden unexpected death in epilepsy (SUDEP) from an archival postmortem series. METHODS In a retrospective study of 187 archival postmortems from 3 groups, SUDEP (68; 14 with hippocampal sclerosis [HS]), non-SUDEP epilepsy controls (EP-C = 66; 25 with HS), and nonepilepsy controls (NEC = 53), Nissl/hematoxylin & eosin-stained sections from left and right hippocampus from 5 coronal levels were digitized. Image analysis was carried out for granule cell layer (GCL) thickness and measurements of hippocampal dimensions (HD) for shape (width [HD1], height [HD2]) and medial hippocampal positioning in relation to the parahippocampal gyrus (PHG) length (HD3). A qualitative evaluation of hippocampal malrotational (HMAL) features, dentate gyrus invaginations (DGI), and subicular/CA1 folds (SCF) was also made. RESULTS GCL thickness was increased in HS more than those without (p < 0.001). In non-HS cases, increased GCL thickness was noted in EP-C compared to NEC (p < 0.05) but not between SUDEP and NEC. There was no difference in the frequency of DGI, SCF, measurements of hippocampal shape (HD1, HD2, or ratio), or medial positioning among SUDEP, EP-C, and NEC groups, when factoring in HS, coronal level, and age at death. Comparison between left and right sides within cases showed greater PHG lengths (HD3) on the right side in the SUDEP group only (p = 0.018). CONCLUSIONS No hippocampal morphometric features were identified in support of either excessive granule cell dispersion or features of HMAL as definitive biomarkers for SUDEP. Asymmetries in PHG measurements in SUDEP warrant further investigation as they may indicate abnormal central autonomic networks.
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Affiliation(s)
- Alyma Somani
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Anita-Beatrix Zborovschi
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Yan Liu
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Smriti Patodia
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Zuzanna Michalak
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Sanjay M Sisodiya
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Maria Thom
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK.
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Buchanan GF. Impaired CO 2-Induced Arousal in SIDS and SUDEP. Trends Neurosci 2019; 42:242-250. [PMID: 30905388 DOI: 10.1016/j.tins.2019.02.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/21/2019] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Premature, sudden death is devastating. Certain patient populations are at greater risk to succumb to sudden death. For instance, infants under 1year of age are at risk for sudden infant death syndrome (SIDS), and patients with epilepsy are at risk for sudden unexpected death in epilepsy (SUDEP). Deaths are attributed to these syndromic entities in these select populations when other diagnoses have been excluded. There are a number of similarities between these syndromes, and the commonalities suggest that the two syndromes may share certain etiological features. One such feature may be deficiency of arousal to CO2. Under normal conditions, CO2 is a potent arousal stimulus. Circumstances surrounding SIDS and SUDEP deaths often facilitate CO2 elevation, and faulty CO2 arousal mechanisms could, at least in part, contribute to death.
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Affiliation(s)
- Gordon F Buchanan
- Department of Neurology and Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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36
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Thom M, Boldrini M, Bundock E, Sheppard MN, Devinsky O. Review: The past, present and future challenges in epilepsy-related and sudden deaths and biobanking. Neuropathol Appl Neurobiol 2019; 44:32-55. [PMID: 29178443 PMCID: PMC5820128 DOI: 10.1111/nan.12453] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/14/2017] [Indexed: 12/14/2022]
Abstract
Awareness and research on epilepsy-related deaths (ERD), in particular Sudden Unexpected Death in Epilepsy (SUDEP), have exponentially increased over the last two decades. Most publications have focused on guidelines that inform clinicians dealing with these deaths, educating patients, potential risk factors and mechanisms. There is a relative paucity of information available for pathologists who conduct these autopsies regarding appropriate post mortem practice and investigations. As we move from recognizing SUDEP as the most common form of ERD toward in-depth investigations into its causes and prevention, health professionals involved with these autopsies and post mortem procedure must remain fully informed. Systematizing a more comprehensive and consistent practice of examining these cases will facilitate (i) more precise determination of cause of death, (ii) identification of SUDEP for improved epidemiological surveillance (the first step for an intervention study), and (iii) biobanking and cell-based research. This article reviews how pathologists and healthcare professionals have approached ERD, current practices, logistical problems and areas to improve and harmonize. The main neuropathology, cardiac and genetic findings in SUDEP are outlined, providing a framework for best practices, integration of clinical, pathological and molecular genetic investigations in SUDEP, and ultimately prevention.
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Affiliation(s)
- M Thom
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK
| | - M Boldrini
- Department of Psychiatry, Columbia University Medical Centre, Divisions of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - E Bundock
- Office of the Chief Medical Examiner, Burlington, VT, USA
| | - M N Sheppard
- Department of Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - O Devinsky
- Department of Neurology, NYU Epilepsy Center, New York, NY, USA
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Elhaik E. Neonatal circumcision and prematurity are associated with sudden infant death syndrome (SIDS). J Clin Transl Res 2019; 4:136-151. [PMID: 30873502 PMCID: PMC6412606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/26/2018] [Accepted: 12/12/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Sudden infant death syndrome (SIDS) is the most common cause of postneonatal unexplained infant death. The allostatic load hypothesis posits that SIDS is the result of cumulative perinatal painful, stressful, or traumatic exposures that tax neonatal regulatory systems. AIMS To test the predictions of the allostatic load hypothesis we explored the relationships between SIDS and two common phenotypes, male neonatal circumcision (MNC) and prematurity. METHODS We collated latitudinal data from 15 countries and 40 US states sampled during 2009 and 2013. We used linear regression analyses and likelihood ratio tests to calculate the association between SIDS and the phenotypes. RESULTS SIDS mortality rate was significantly and positively correlated with MNC. Globally (weighted): Increase of 0.06 (95% CI: 0.01-0.1, t = 2.86, p = 0.01) per 1000 SIDS mortality per 10% increase in circumcision rate. US (weighted): Increase of 0.1 (95% CI: 0.03-0.16, t = 2.81, p = 0.01) per 1000 unexplained mortality per 10% increase in circumcision rate. US states in which Medicaid covers MNC had significantly higher MNC rates (χ̄ = 0.72 vs 0.49, p = 0.007) and male/female ratio of SIDS deaths (χ̄ = 1.48 vs 1.125, p = 0.015) than other US states. Prematurity was also significantly and positively correlated with MNC. Globally: Increase of 0.5 (weighted: 95% CI: 0.02-0.086, t = 3.37, p = 0.004) per 1000 SIDS mortality per 10% increase in the prematurity rates. US: Increase of 1.9 (weighted: 95% CI: 0.06-0.32, t = 3.13, p = 0.004) per 1000 unexplained mortalities per 10% increase in the prematurity rates. Combined, the phenotypes increased the likelihood of SIDS. CONCLUSIONS Epidemiological analyses are useful to generate hypotheses but cannot provide strong evidence of causality. Biological plausibility is provided by a growing body of experimental and clinical evidence linking aversive preterm and early-life SIDS events. Together with historical and anthropological evidence, our findings emphasize the necessity of cohort studies that consider these phenotypes with the aim of improving the identification of at-risk infants and reducing infant mortality. RELEVANCE FOR PATIENTS Preterm birth and neonatal circumcision are associated with a greater risk of SIDS, and efforts should be focused on reducing their rates.
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Affiliation(s)
- Eran Elhaik
- Department of Animal and Plant Sciences, University of Sheffield, UK
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38
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39
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Tester DJ, Wong LCH, Chanana P, Gray B, Jaye A, Evans JM, Evans M, Fleming P, Jeffrey I, Cohen M, Tfelt-Hansen J, Simpson MA, Behr ER, Ackerman MJ. Exome-Wide Rare Variant Analyses in Sudden Infant Death Syndrome. J Pediatr 2018; 203:423-428.e11. [PMID: 30268395 PMCID: PMC6394853 DOI: 10.1016/j.jpeds.2018.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/27/2018] [Accepted: 08/08/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine whether a monogenic basis explains sudden infant death syndrome (SIDS) using an exome-wide focus. STUDY DESIGN A cohort of 427 unrelated cases of SIDS (257 male; average age = 2.7 ± 1.9 months) underwent whole-exome sequencing. Exome-wide rare variant analyses were carried out with 278 SIDS cases of European ancestry (173 male; average age = 2.7 ± 1.98 months) and 973 ethnic-matched controls based on 6 genetic models. Ingenuity Pathway Analysis also was performed. The cohort was collected in collaboration with coroners, medical examiners, and pathologists by St George's University of London, United Kingdom, and Mayo Clinic, Rochester, Minnesota. Whole-exome sequencing was performed at the Genomic Laboratory, Kings College London, United Kingdom, or Mayo Clinic's Medical Genome Facility, Rochester, Minnesota. RESULTS Although no exome-wide significant (P < 2.5 × 10-6) difference in burden of ultra-rare variants was detected for any gene, 405 genes had a greater prevalence (P < .05) of ultra-rare nonsynonymous variants among cases with 17 genes at P < .005. Some of these potentially overrepresented genes may represent biologically plausible novel candidate genes for a monogenic basis for a portion of patients with SIDS. The top canonical pathway identified was glucocorticoid biosynthesis (P = .01). CONCLUSIONS The lack of exome-wide significant genetic associations indicates an extreme heterogeneity of etiologies underlying SIDS. Our approach to understanding the genetic mechanisms of SIDS has far reaching implications for the SIDS research community as a whole and may catalyze new evidence-based SIDS research across multiple disciplines. Perturbations in glucocorticoid biosynthesis may represent a novel SIDS-associated biological pathway for future SIDS investigative research.
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Affiliation(s)
- David J Tester
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Pediatrics (Division of Pediatric Cardiology), Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN
| | - Leonie C H Wong
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Cardiology Clinical Academic Group, St George's University Hospitals' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Pritha Chanana
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Belinda Gray
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Cardiology Clinical Academic Group, St George's University Hospitals' National Health Service (NHS) Foundation Trust, London, United Kingdom; Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amie Jaye
- Medical and Molecular Genetics, Guy's Hospital, King's College London, London, United Kingdom
| | - Jared M Evans
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Margaret Evans
- Department of Pathology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Peter Fleming
- Centre for Child and Adolescent Health, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Iona Jeffrey
- Department of Cellular Pathology, St George's University of London, London, United Kingdom; Department of Cellular Pathology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Marta Cohen
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, United Kingdom
| | - Jacob Tfelt-Hansen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael A Simpson
- Medical and Molecular Genetics, Guy's Hospital, King's College London, London, United Kingdom
| | - Elijah R Behr
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Cardiology Clinical Academic Group, St George's University Hospitals' National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Michael J Ackerman
- Department of Cardiovascular Medicine (Division of Heart Rhythm Services), Pediatrics (Division of Pediatric Cardiology), Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN.
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40
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Abstract
A wide variety of neuropathological abnormalities have been investigated in infants who have died of sudden infant death syndrome (SIDS). Issues which detracted from early studies included failure to use uniform definitions of SIDS and lack of appropriately matched control populations. Development of the triple risk model focused attention on the concept of an inherent susceptibility to unexpected death in certain infants, with research demonstrating a role for the neurotransmitter serotonin within the brainstem. However, it now appears that neuropathological abnormalities in SIDS infants are more complex than a simple serotonergic deficiency in certain medullary nuclei but instead could involve failure of an integrated network of neurochemical transmitters in a variety of subcortical locations. The following overview examines recent research developments looking particularly at the potential role of the peptide neurotransmitter substance P and its neurokinin-1 receptor in multiple nuclei within the brainstem, asymmetry and microdysgenesis of the hippocampus, and decreased orexin levels within dorsomedial, perifornical, and lateral levels in the hypothalamus. Whether such research will lead to identifiable biomarker for infants at risk of SIDS is yet to be established. Use of standardized and consistent methods of classifying and categorizing infant deaths will be pivotal in generating reproducible research results.
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Affiliation(s)
- Fiona M Bright
- 1 School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Vink
- 2 Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Roger W Byard
- 1 School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Brownstein CA, Goldstein RD, Thompson CH, Haynes RL, Giles E, Sheidley B, Bainbridge M, Haas EA, Mena OJ, Lucas J, Schaber B, Holm IA, George AL, Kinney HC, Poduri AH. SCN1A variants associated with sudden infant death syndrome. Epilepsia 2018; 59:e56-e62. [PMID: 29601086 DOI: 10.1111/epi.14055] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 12/27/2022]
Abstract
We identified SCN1A variants in 2 infants who died of sudden infant death syndrome (SIDS) with hippocampal abnormalities from an exome sequencing study of 10 cases of SIDS but no history of seizures. One harbored SCN1A G682V, and the other had 2 SCN1A variants in cis: L1296M and E1308D, a variant previously associated with epilepsy. Functional evaluation in a heterologous expression system demonstrated partial loss of function for both G682V and the compound variant L1296M/E1308D. Our cases represent a novel association between SCN1A and SIDS, extending the SCN1A spectrum from epilepsy to SIDS. Our findings provide insights into SIDS and support genetic evaluation focused on epilepsy genes in SIDS.
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Affiliation(s)
- Catherine A Brownstein
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Genetics and Genomics, Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard D Goldstein
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Christopher H Thompson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robin L Haynes
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Emma Giles
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Beth Sheidley
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | | | - Elisabeth A Haas
- Department of Pathology, Rady Children's Hospital-San Diego, San Diego, CA, USA
| | - Othon J Mena
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Jonathan Lucas
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Bethann Schaber
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Ingrid A Holm
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Genetics and Genomics, Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Alfred L George
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hannah C Kinney
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Annapurna H Poduri
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, F. M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
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42
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Armstrong DD. Autobiography Series: Some Remembrances About Education and Neuropathology Studies. J Neuropathol Exp Neurol 2017; 76:917-921. [PMID: 28922854 DOI: 10.1093/jnen/nlx069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Despite decades of investigation and millions of dollars spent, the cause of sudden infant death syndrome (SIDS) eludes researchers. It is timely therefore to reconsider the reasons for this failure and to explore how research might go forward with better prospects. This review assesses SIDS research in the context of clinicopathological and epidemiological features and determines that only infection attains congruence.
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44
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Folkerth RD, Nunez J, Georgievskaya Z, McGuone D. Neuropathologic Examination in Sudden Unexpected Deaths in Infancy and Childhood: Recommendations for Highest Diagnostic Yield and Cost-Effectiveness in Forensic Settings. Acad Forensic Pathol 2017; 7:182-199. [PMID: 31239973 PMCID: PMC6474536 DOI: 10.23907/2017.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/30/2017] [Accepted: 04/30/2017] [Indexed: 11/12/2022]
Abstract
In infants and toddlers (less than four years of age), determination of cause and manner of death often requires a complete autopsy. Few evidence-based guidelines exist regarding optimum nervous system sectioning in this population. Over a six-month interval and using a comprehensive section protocol, we categorized cases having neuropathological findings that were critical (Class A), contributory (Class B), or noncontributory (Class C) to the final cause and manner of death. We further evaluated which sections helped make this determination. Among 53 cases (44 infants, 9 toddlers; 26 girls, 27 boys), Class A neuropathology was noted in nine (16.9%). Seven infants had meningoencephalitis (2/7, 28.6%), craniospinal trauma (3/7, 42.8%), brainstem necrosis suggesting Leigh Disease (1/7, 14.3%), and hydrocephalus in Dandy-Walker malformation (1/7, 14.3%); two toddlers had inflicted craniospinal trauma (2/2, 100%). Class B factors were identified in 11/53 (20.8%), including recent hypoxic-ischemic lesions (2/11, 18.2%), meningitis or dural venous sinus thrombosis in systemic sepsis (2/11, 18.2%), multicystic encephalopathy following peripartum asphyxia (2/11, 18.2%), and microcephaly and delayed myelination (Cri-du-Chat Syndrome) (1/11, 9.09%). Class B also included three toddlers (3/11, 27.2%) with features of hippocampal dysgenesis, two in the setting of febrile seizures. Class C comprised normal brains (3/53, 5.7%), and those with findings of uncertain significance, such as white matter and brainstem gliosis (30/53, 56.6%). The sections most valuable for detection of relevant pathology, and thus recommended for routine sampling, were: 1) bilateral hippocampus; 2) cerebral cortex and leptomeninges; and 3) pons or medulla.
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Affiliation(s)
- Rebecca D. Folkerth
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Jacqueline Nunez
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Zhanna Georgievskaya
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
| | - Declan McGuone
- City of New York Office of the Chief Medical Examiner and New
York University School of Medicine - Forensic Medicine
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45
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Michalak Z, Obari D, Ellis M, Thom M, Sisodiya SM. Neuropathology of SUDEP: Role of inflammation, blood-brain barrier impairment, and hypoxia. Neurology 2017; 88:551-561. [PMID: 28087824 PMCID: PMC5304466 DOI: 10.1212/wnl.0000000000003584] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 11/09/2016] [Indexed: 12/12/2022] Open
Abstract
Objective: To seek a neuropathologic signature of sudden unexpected death in epilepsy (SUDEP) in a postmortem cohort by use of immunohistochemistry for specific markers of inflammation, gliosis, acute neuronal injury due to hypoxia, and blood-brain barrier (BBB) disruption, enabling the generation of hypotheses about potential mechanisms of death in SUDEP. Methods: Using immunohistochemistry, we investigated the expression of 6 markers (CD163, human leukocyte antigen–antigen D related, glial fibrillary acid protein, hypoxia-inducible factor-1α [HIF-1α], immunoglobulin G, and albumin) in the hippocampus, amygdala, and medulla in 58 postmortem cases: 28 SUDEP (definite and probable), 12 epilepsy controls, and 18 nonepileptic sudden death controls. A semiquantitative measure of immunoreactivity was scored for all markers used, and quantitative image analysis was carried out for selected markers. Results: Immunoreactivity was observed for all markers used within all studied brain regions and groups. Immunoreactivity for inflammatory reaction, BBB leakage, and HIF-1α in SUDEP cases was not different from that seen in control groups. Conclusions: This study represents a starting point to explore by immunohistochemistry the mechanisms underlying SUDEP in human brain tissue. Our approach highlights the potential and importance of considering immunohistochemical analysis to help identify biomarkers of SUDEP. Our results suggest that with the markers used, there is no clear immunohistochemical signature of SUDEP in human brain.
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Affiliation(s)
- Zuzanna Michalak
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Dima Obari
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Matthew Ellis
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Maria Thom
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Sanjay M Sisodiya
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK.
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Squier W, Mack J, Jansen AC. Infants dying suddenly and unexpectedly share demographic features with infants who die with retinal and dural bleeding: a review of neural mechanisms. Dev Med Child Neurol 2016; 58:1223-1234. [PMID: 27435495 DOI: 10.1111/dmcn.13202] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 01/01/2023]
Abstract
The cause of death in infants who die suddenly and unexpectedly (sudden unexpected death in infancy [SUDI]) remains a diagnostic challenge. Some infants have identified diseases (explained SUDI); those without explanation are called sudden infant death syndrome (SIDS). Demographic data indicate subgroups among SUDI and SIDS cases, such as unsafe sleeping and apparent life-threatening events. Infants dying suddenly with retinal and dural bleeding are often classified as abused, but in many there is no evidence of trauma. Demographic features suggest that they may represent a further subgroup of SUDI. This review examines the neuropathological hypotheses to explain SIDS and highlights the interaction of infant oxygen-conserving reflexes with the brainstem networks considered responsible for SIDS. We consider sex- and age-specific vulnerabilities related to dural bleeding and how sensitization of the dural innervation by bleeding may influence these reflexes, potentially leading to collapse or even death after otherwise trivial insults.
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Affiliation(s)
- Waney Squier
- Formerly Department of Neuropathology, Oxford University John Radcliffe Hospital, Oxford, UK
| | - Julie Mack
- Department of Radiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Anna C Jansen
- Paediatric Neurology Unit, Department of Paediatrics, UZ Brussel, Brussels, Belgium.,Neurogenetics Research Unit, Vrije Universiteit Brussel, Brussels, Belgium
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Moon RY. SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2016; 138:peds.2016-2940. [PMID: 27940805 DOI: 10.1542/peds.2016-2940] [Citation(s) in RCA: 350] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Approximately 3500 infants die annually in the United States from sleep-related infant deaths, including sudden infant death syndrome (SIDS), ill-defined deaths, and accidental suffocation and strangulation in bed. After an initial decrease in the 1990s, the overall sleep-related infant death rate has not declined in more recent years. Many of the modifiable and nonmodifiable risk factors for SIDS and other sleep-related infant deaths are strikingly similar. The American Academy of Pediatrics recommends a safe sleep environment that can reduce the risk of all sleep-related infant deaths. Recommendations for a safe sleep environment include supine positioning, use of a firm sleep surface, room-sharing without bed-sharing, and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include avoidance of exposure to smoke, alcohol, and illicit drugs; breastfeeding; routine immunization; and use of a pacifier. New evidence and rationale for recommendations are presented for skin-to-skin care for newborn infants, bedside and in-bed sleepers, sleeping on couches/armchairs and in sitting devices, and use of soft bedding after 4 months of age. In addition, expanded recommendations for infant sleep location are included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment," which is included in this issue.
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48
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Panigrahy A, Lee V, Ceschin R, Zuccoli G, Beluk N, Khalifa O, Votava-Smith JK, DeBrunner M, Munoz R, Domnina Y, Morell V, Wearden P, De Toledo JS, Devine W, Zahid M, Lo CW. Brain Dysplasia Associated with Ciliary Dysfunction in Infants with Congenital Heart Disease. J Pediatr 2016; 178:141-148.e1. [PMID: 27574995 PMCID: PMC5085835 DOI: 10.1016/j.jpeds.2016.07.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/03/2016] [Accepted: 07/27/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To test for associations between abnormal respiratory ciliary motion (CM) and brain abnormalities in infants with congenital heart disease (CHD) STUDY DESIGN: We recruited 35 infants with CHD preoperatively and performed nasal tissue biopsy to assess respiratory CM by videomicroscopy. Cranial ultrasound scan and brain magnetic resonance imaging were obtained pre- and/or postoperatively and systematically reviewed for brain abnormalities. Segmentation was used to quantitate cerebrospinal fluid and regional brain volumes. Perinatal and perioperative clinical variables were collected. RESULTS A total of 10 (28.5%) patients with CHD had abnormal CM. Abnormal CM was not associated with brain injury but was correlated with increased extraaxial cerebrospinal fluid volume (P < .001), delayed brain maturation (P < .05), and a spectrum of subtle dysplasia including the hippocampus (P < .0078) and olfactory bulb (P < .034). Abnormal CM was associated with higher composite dysplasia score (P < .001), and both were correlated with elevated preoperative serum lactate (P < .001). CONCLUSIONS Abnormal respiratory CM in infants with CHD is associated with a spectrum of brain dysplasia. These findings suggest that ciliary defects may play a role in brain dysplasia in patients with CHD and have the potential to prognosticate neurodevelopmental risks.
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Affiliation(s)
- Ashok Panigrahy
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA.
| | - Vincent Lee
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Rafael Ceschin
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Nancy Beluk
- Department of Pediatric Radiology, Childrens Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine
| | - Omar Khalifa
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jodie K Votava-Smith
- Department of Pediatric, Division of Cardiology, Childrens Hospital of Los Angeles., Los Angeles, CA
| | - Mark DeBrunner
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ricardo Munoz
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yuliya Domnina
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Victor Morell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter Wearden
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joan Sanchez De Toledo
- Cardiac Intensive Care Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - William Devine
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maliha Zahid
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cecilia W. Lo
- Dept. of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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49
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Kinney HC, Poduri AH, Cryan JB, Haynes RL, Teot L, Sleeper LA, Holm IA, Berry GT, Prabhu SP, Warfield SK, Brownstein C, Abram HS, Kruer M, Kemp WL, Hargitai B, Gastrang J, Mena OJ, Haas EA, Dastjerdi R, Armstrong DD, Goldstein RD. Hippocampal Formation Maldevelopment and Sudden Unexpected Death across the Pediatric Age Spectrum. J Neuropathol Exp Neurol 2016; 75:981-997. [PMID: 27612489 PMCID: PMC6281079 DOI: 10.1093/jnen/nlw075] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Sudden infant death syndrome (SIDS) and sudden unexplained death in childhood (SUDC) are defined as sudden death in a child remaining unexplained despite autopsy and death scene investigation. They are distinguished from each other by age criteria, i.e. with SIDS under 1 year and SUDC over 1 year. Our separate studies of SIDS and SUDC provide evidence of shared hippocampal abnormalities, specifically focal dentate bilamination, a lesion classically associated with temporal lobe epilepsy, across the 2 groups. In this study, we characterized the clinicopathologic features in a retrospective case series of 32 children with sudden death and hippocampal formation (HF) maldevelopment. The greatest frequency of deaths was between 3 weeks and 3 years (81%, 26/32). Dentate anomalies were found across the pediatric age spectrum, supporting a common vulnerability that defies the 1-year age cutoff between SIDS and SUDC. Twelve cases (38%) had seizures, including 7 only with febrile seizures. Subicular anomalies were found in cases over 1 year of age and were associated with increased risk of febrile seizures. Sudden death associated with HF maldevelopment reflects a complex interaction of intrinsic and extrinsic factors that lead to death at different pediatric ages, and may be analogous to sudden unexplained death in epilepsy.
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Affiliation(s)
- Hannah C Kinney
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Annapurna H Poduri
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Jane B Cryan
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Robin L Haynes
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Lisa Teot
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Lynn A Sleeper
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Ingrid A Holm
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Gerald T Berry
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Sanjay P Prabhu
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Simon K Warfield
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Catherine Brownstein
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Harry S Abram
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Michael Kruer
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Walter L Kemp
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Beata Hargitai
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Joanne Gastrang
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Othon J Mena
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Elisabeth A Haas
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Roya Dastjerdi
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Dawna D Armstrong
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
| | - Richard D Goldstein
- From the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (HCK, RLH, LT, RD); Epilepsy Genetics Program, Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (AHP); Division of Neuropathology, Beaumont Hospital, Dublin, Ireland (JBC); Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (LAS); Department of Genetics and Genomic Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (IAH, GTB, CB); Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (SPP, SKW); Division of Child Neurology, Nemours Children's Specialty Care, Jacksonville, Florida (HAS); Barrow Neurological Institute, Phoenix Children's Hospital, Department of Child Health, University of Arizona College of Medicine Phoenix Children's Hospital, Phoenix, Arizona (MK); Department of Pathology, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (WLK); Department of Cellular Pathology Birmingham Women's Hospital, Birmingham, UK (BH); Division of Mental Health and Wellbeing, University of Warwick, and Coventry and Warwickshire Partnership NHS Trust, Coventry, UK (JG); Office of the Medical Examiner, County of San Diego, California (OJM); Department of Pathology, Rady Children's Hospital, San Diego, California (EAH); Department of Pathology, Baylor College of Medicine, Retired Professor of Pathology, Houston, Texas (DDA); Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts (RDG)
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Devinsky O, Hesdorffer DC, Thurman DJ, Lhatoo S, Richerson G. Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention. Lancet Neurol 2016; 15:1075-88. [DOI: 10.1016/s1474-4422(16)30158-2] [Citation(s) in RCA: 369] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/24/2022]
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