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Salluce C, Cocciante M, Gazzillo M, Ferrari AR, Battini R, Santorelli FM, Bartolini E. Children and Young Adults with Epilepsy Exhibit an Interictal Autonomic Dysfunction: A Prospective Exploratory Study. Brain Sci 2024; 14:670. [PMID: 39061411 PMCID: PMC11274926 DOI: 10.3390/brainsci14070670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/25/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
Dysautonomic disorders are an increasingly studied group of conditions, either as isolated diseases or associated with other neurological disorders. There is growing interest in understanding how dysautonomia affects people with epilepsy, who may report autonomic symptoms before, during and after seizures. Furthermore, autonomic abnormalities appear to play a role in sudden unexpected death in epilepsy, likely contributing to the increased mortality rate described in epilepsy. To better understand the association between epilepsy and dysautonomia, we explored electrochemical skin conductance in a group of 18 children and young adults with epilepsy compared to 15 age- and sex-matched healthy controls by the SudoscanTM test. We found a significant difference in terms of electrochemical skin conductance, suggesting that people with epilepsy suffer significantly reduced conductance in small nerve fibers. Within patients, values were significantly different according to the type of epilepsy and to neuroimaging results, with lower conductance values in epilepsies of unknown origin and in patients with morphological abnormalities of the brain. Using a non-invasive test, we identified altered conductance of small sympathetic nerve fibers in children and young adults with epilepsy, suggesting underlying dysautonomia. Further studies are needed to investigate this association and to clarify its neurobiological substrates.
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Affiliation(s)
- Carmen Salluce
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Marco Cocciante
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Marisa Gazzillo
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
- Division of Pediatric Neurology, Department of Neurosciences, Santobono-Pausillipon Children’s Hospital, 80129 Naples, Italy
| | - Anna Rita Ferrari
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
| | - Roberta Battini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Filippo Maria Santorelli
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
| | - Emanuele Bartolini
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128 Pisa, Italy; (C.S.); (M.C.); (M.G.); (A.R.F.); (R.B.); (F.M.S.)
- Tuscany PhD Program in Neurosciences, 50139 Florence, Italy
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Hamed SA, El Hadad AF, Aladawy MA. The effect of epilepsy and antiseizure medications on cardiac autonomic functions in children with epilepsy. Expert Rev Clin Pharmacol 2024; 17:393-401. [PMID: 38349326 DOI: 10.1080/17512433.2024.2318469] [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: 12/13/2023] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Autonomic manifestations have been frequently studied in adults with epilepsy. Here, we evaluated cardiac autonomic (ANS) functions in children with epilepsy in the interictal period and determined the risks for their dysfunctions. RESEARCH DESIGN AND METHODS This study included 60 patients (boys = 25; girls = 35 age: 14.53 ± 2.54 yrs) and 25 controls. Patients were well-controlled on antiseizure medications (ASMs). The battery of testing included measuring resting heart rate (HR) and blood pressure (BP), 30:15 ratio, HR variability (HRV) response to deep breathing, Valsalva ratio and BP changes in response to standing, isometric exercise and cold. RESULTS Dizziness was reported in 25%. Autonomic dysfunctions were found in 45% (n = 27). Manifestations included high frequencies of abnormal 30:15 ratio (22%), HRV responses to deep breathing (45%), Valsalava ratio (45%), and BP responses to standing (35%), isometric exercise (27%) and cold (27%), indicating parasympathetic and sympathetic hypofunctions. There were positive correlations between parasympathetic and sympathetic dysfunctions. Logistic analysis showed that the durations of epilepsy and ASMs therapy were associated with ANS dysfunctions [95% CI: 0.895-4.719, p = 0.004]. CONCLUSIONS Parasympathetic and sympathetic autonomic hypofunctions are common in children with epilepsy. This could be due to the depressant effect of sodium channel blocker ASMs on central and/or cardiac autonomic systems.
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Affiliation(s)
- Sherifa Ahmed Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, Assiut, Egypt
| | - Ali Farrag El Hadad
- Department of Neurology and Psychiatry, Al Azhar University Hospital, Assiut, Egypt
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Ryan JM, Wagner KT, Yerram S, Concannon C, Lin JX, Rooney P, Hanrahan B, Titoff V, Connolly NL, Cranmer R, DeMaria N, Xia X, Mykins B, Erickson S, Couderc JP, Schifitto G, Hughes I, Wang D, Erba G, Auerbach DS. Heart rate and autonomic biomarkers distinguish convulsive epileptic vs. functional or dissociative seizures. Seizure 2023; 111:178-186. [PMID: 37660533 DOI: 10.1016/j.seizure.2023.08.015] [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: 06/09/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE 20-40% of individuals whose seizures are not controlled by anti-seizure medications exhibit manifestations comparable to epileptic seizures (ES), but there are no EEG correlates. These events are called functional or dissociative seizures (FDS). Due to limited access to EEG-monitoring and inconclusive results, we aimed to develop an alternative diagnostic tool that distinguishes ES vs. FDS. We evaluated the temporal evolution of ECG-based measures of autonomic function (heart rate variability, HRV) to determine whether they distinguish ES vs. FDS. METHODS The prospective study includes patients admitted to the University of Rochester Epilepsy Monitoring Unit. Participants are 18-65 years old, without therapies or co-morbidities associated with altered autonomics. A habitual ES or FDS is recorded during admission. HRV analysis is performed to evaluate the temporal changes in autonomic function during the peri‑ictal period (150-minutes each pre-/post-ictal). We determined if autonomic measures distinguish ES vs. FDS. RESULTS The study includes 53 ES and 46 FDS. Temporal evolution of HR and autonomics significantly differ surrounding ES vs. FDS. The pre-to-post-ictal change (delta) in HR differs surrounding ES vs. FDS, stratified for convulsive and non-convulsive events. Post-ictal HR, total autonomic (SDNN & Total Power), vagal (RMSSD & HF), and baroreflex (LF) function differ for convulsive ES vs. convulsive FDS. HR distinguishes non-convulsive ES vs. non-convulsive FDS with ROC>0.7, sensitivity>70%, but specificity<50%. HR-delta and post-ictal HR, SDNN, RMSSD, LF, HF, and Total Power each distinguish convulsive ES vs. convulsive FDS (ROC, 0.83-0.98). Models with HR-delta and post-ictal HR provide the highest diagnostic accuracy for convulsive ES vs. convulsive FDS: 92% sensitivity, 94% specificity, ROC 0.99). SIGNIFICANCE HR and HRV measures accurately distinguish convulsive, but not non-convulsive, events (ES vs. FDS). Results establish the framework for future studies to apply this diagnostic tool to more heterogeneous populations, and on out-of-hospital recordings, particularly for populations without access to epilepsy monitoring units.
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Affiliation(s)
- Justin M Ryan
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Kyle T Wagner
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Sushma Yerram
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Cathleen Concannon
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Jennifer X Lin
- School of Medicine, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Patrick Rooney
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Brian Hanrahan
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Victoria Titoff
- Department of Neurology-Epilepsy, SUNY Upstate Medical University, Syracuse, NY 13210, United States; Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Noreen L Connolly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Ramona Cranmer
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Natalia DeMaria
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaojuan Xia
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Betty Mykins
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Steven Erickson
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Jean-Philippe Couderc
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Inna Hughes
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Dongliang Wang
- Department of Public Health, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Giuseppe Erba
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States.
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Doerr JM, Juenemann M, Hakel L, Schmidt L, Menzler K, Krause K, Linka L, Skoluda N, Nater UM, Knake S. Effect of transcutaneous vagus nerve stimulation on stress-reactive neuroendocrine measures in a sample of persons with temporal lobe epilepsy. Epilepsia Open 2023; 8:1013-1020. [PMID: 37310988 PMCID: PMC10472404 DOI: 10.1002/epi4.12774] [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: 03/29/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE Dysregulation of stress-reactive neuroendocrine measures, as well as subjective stress, have been found to worsen epilepsy. Transcutaneous vagus nerve stimulation (tVNS) is a relatively new treatment option for epilepsy. We were interested in its effect on the activity of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS) as well as subjective stress and tiredness in patients with temporal lobe epilepsy (TLE). METHODS Twenty patients (age 44 ± 11 years, 13 women) were enrolled in the study. They were free of seizures for more than 1 year. All took part in two sessions with 4 h of stimulation (tVNS vs. sham) in a randomized order. Saliva samples and subjective stress and tiredness levels were measured at five time points each session (before and after stimulation and three time points every hour in between). Data were analyzed using repeated measures analysis of variance as well as paired t-tests. RESULTS There was a dampened salivary cortisol (sCort) decrease during tVNS (time × condition effect: F[2.38, 38.15] = 6.50, P = 0.002, partial η2 = 0.29). Furthermore, we detected a dampened increase in salivary flow rate during tVNS (time × condition effect: F[3.28, 55.67] = 2.82, P = 0.043, partial η2 = 0.14). There was neither a difference in overall sCort or salivary alpha-amylase (sAA) levels nor in subjective stress or tiredness levels between conditions. sAA levels at the last measurement point were slightly higher during tVNS (t(19) = 2.26, P = 0.035, d = 0.51), but this effect failed to reach significance when controlled for multiple comparisons. SIGNIFICANCE Our results partially support that tVNS influences the regulation of stress-reactive neuroendocrine systems (namely the HPA axis and ANS) in epilepsy. More research with larger samples is needed on the difference between short-term and repeated long-term stimulation.
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Affiliation(s)
- Johanna M. Doerr
- Department of NeurologyUniversity Hospital Gießen and MarburgGießenGermany
| | - Martin Juenemann
- Department of NeurologyUniversity Hospital Gießen and MarburgGießenGermany
| | - Lukas Hakel
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Laura Schmidt
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Katja Menzler
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Kristina Krause
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Louise Linka
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Nadine Skoluda
- Department of Clinical and Health Psychology, Faculty of PsychologyUniversity of ViennaViennaAustria
| | - Urs M. Nater
- Department of Clinical and Health Psychology, Faculty of PsychologyUniversity of ViennaViennaAustria
| | - Susanne Knake
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
- Center for Mind, Brain and Behavior (CMBB)Philipps‐University MarburgMarburgGermany
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You SM, Cho BH, Bae HE, Kim YK, Kim JR, Park SR, Shon YM, Seo DW, Kim IY. Exploring Autonomic Alterations during Seizures in Temporal Lobe Epilepsy: Insights from a Heart-Rate Variability Analysis. J Clin Med 2023; 12:4284. [PMID: 37445319 DOI: 10.3390/jcm12134284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
Epilepsy's impact on cardiovascular function and autonomic regulation, including heart-rate variability, is complex and may contribute to sudden unexpected death in epilepsy (SUDEP). Lateralization of autonomic control in the brain remains the subject of debate; nevertheless, ultra-short-term heart-rate variability (HRV) analysis is a useful tool for understanding the pathophysiology of autonomic dysfunction in epilepsy patients. A retrospective study reviewed medical records of patients with temporal lobe epilepsy who underwent presurgical evaluations. Data from 75 patients were analyzed and HRV indices were extracted from electrocardiogram recordings of preictal, ictal, and postictal intervals. Various HRV indices were calculated, including time domain, frequency domain, and nonlinear indices, to assess autonomic function during different seizure intervals. The study found significant differences in HRV indices based on hemispheric laterality, language dominancy, hippocampal atrophy, amygdala enlargement, sustained theta activity, and seizure frequency. HRV indices such as the root mean square of successive differences between heartbeats, pNN50, normalized low-frequency, normalized high-frequency, and the low-frequency/high-frequency ratio exhibited significant differences during the ictal period. Language dominancy, hippocampal atrophy, amygdala enlargement, and sustained theta activity were also found to affect HRV. Seizure frequency was correlated with HRV indices, suggesting a potential relationship with the risk of SUDEP.
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Affiliation(s)
- Sung-Min You
- Department of Biomedical Engineering, Hanyang University, Seoul 04763, Republic of Korea
- Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Baek-Hwan Cho
- Department of Biomedical Informatics, School of Medicine, CHA University, Seongnam 13488, Republic of Korea
- Institute of Biomedical Informatics, School of Medicine, CHA University, Seongnam 13488, Republic of Korea
| | - Hyo-Eun Bae
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Young-Kyun Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jae-Rim Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Soo-Ryun Park
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Young-Min Shon
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Neuroscience Center, Samsung Medical Center, Seoul 06351, Republic of Korea
| | - Dae-Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Neuroscience Center, Samsung Medical Center, Seoul 06351, Republic of Korea
| | - In-Young Kim
- Department of Biomedical Engineering, Hanyang University, Seoul 04763, Republic of Korea
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Assessing epilepsy-related autonomic manifestations: Beyond cardiac and respiratory investigations. Neurophysiol Clin 2023; 53:102850. [PMID: 36913775 DOI: 10.1016/j.neucli.2023.102850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/13/2023] Open
Abstract
The Autonomic Nervous System (ANS) regulates many critical physiological functions. Its control relies on cortical input, especially limbic areas, which are often involved in epilepsy. Peri-ictal autonomic dysfunction is now well documented, but inter-ictal dysregulation is less studied. In this review, we discuss the available data on epilepsy-related autonomic dysfunction and the objective tests available. Epilepsy is associated with sympathetic-parasympathetic imbalance and a shift towards sympathetic dominance. Objective tests report alterations in heart rate, baroreflex function, cerebral autoregulation, sweat glands activity, thermoregulation, gastrointestinal and urinary function. However, some tests have found contradictory results and many tests suffer from a lack of sensitivity and reproducibility. Further study on interictal ANS function is required to further understand autonomic dysregulation and the potential association with clinically-relevant complications, including risk of Sudden Unexpected Death In Epilepsy (SUDEP).
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Athira SB, Pal P, Nair PP, Nanda N, Aghoram R. Cardiovascular autonomic function and baroreflex sensitivity in drug-resistant temporal lobe epilepsy. Epilepsy Behav 2023; 138:109013. [PMID: 36525923 DOI: 10.1016/j.yebeh.2022.109013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Temporal lobe epilepsy (TLE) is often associated with autonomic manifestations. Sudden unexpected death in epilepsy (SUDEP) is a leading cause of mortality in epilepsy. Cardiac disturbances and autonomic dysfunction are the potential mechanisms behind SUDEP. Though heart rate variability (HRV) and autonomic function tests are well studied in drug-resistant temporal lobe epilepsy, there is a paucity of data on baroreflex sensitivity (BRS), a better marker of cardiac mortality in this population. We aimed to study the interictal cardiac autonomic function and BRS in people living with drug-resistant temporal lobe epilepsy compared to healthy controls. MATERIALS AND METHODS Thirty drug-resistant temporal lobe epilepsy (TLE) individuals and thirty healthy volunteers were recruited. Heart rate variability at rest, heart rate and blood pressure (BP) at rest, during deep breathing, postural change, BP response to isometric handgrip exercise, and baroreflex sensitivity were recorded in all study participants. The results were analyzed and compared between the two groups. RESULTS Compared to controls, the resting heart rate, HRV, parasympathetic reactivity test, and BRS significantly differed in people living with drug-resistant TLE. Time-domain indices including SDNN (p < 0.001), RMSSD (p < 0.001), NN50 (p < 0.001), and pNN50 (p < 0.001) were significantly reduced in the patients compared to controls. In frequency-domain indices, the total power was reduced (p < 0.001) in drug-resistant TLE. The parasympathetic reactivity such as changes in heart rate during deep breathing (E: I) (p < 0.02) and postural change (30:15) (p < 0.005) were significantly reduced in the patients. Baroreflex sensitivity was also significantly reduced in the drug-resistant TLE group (p < 0.001). CONCLUSION The present study findings are suggestive of parasympathetic dysfunction in drug-resistant TLE. Reduced HRV and BRS may increase the risk of SUDEP in people living with epilepsy.
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Affiliation(s)
- S B Athira
- Department of Physiology, JPMER, Puducherry 605006, India.
| | - Pravati Pal
- Department of Physiology, JPMER, Puducherry 605006, India.
| | - Pradeep P Nair
- Department of Neurology, JPMER, Puducherry 605006, India.
| | - Nivedita Nanda
- Department of Biochemistry, JPMER, Puducherry 605006, India.
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Haridas B, Chuang DT, Nei M, Kang JY. Sudden Unexpected Death in Epilepsy: Pathogenesis, Risk Factors, and Prevention. Semin Neurol 2022; 42:658-664. [PMID: 36223819 DOI: 10.1055/a-1960-1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a tragic and unexpected cause of death in patients with a known diagnosis of epilepsy. It occurs in up to 6.3 to 9.3/1,000 patients with drug-resistant epilepsy. The main three risk factors associated with SUDEP are the presence of generalized tonic-clonic seizures, the presence of a seizure in the past year, and an intellectual disability. There are several mechanisms that can result in SUDEP. The most likely sequence of events appears to be a convulsive seizure, overactivation of the autonomic nervous system, cardiorespiratory dysfunction, and death. While the risk of SUDEP is relatively high in patients with drug-resistant epilepsy, studies indicate that more than 50% of patients and caregivers are unaware of the diagnosis. Counseling about the diagnosis and preventative measures at the time of diagnosis is important. There are numerous interventions that may reduce the risk of SUDEP, including conservative measures such as nocturnal surveillance with a bed partner (where applicable) and automated devices. Optimizing seizure control with antiseizure medications and surgical interventions can result in a reduced risk of SUDEP.
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Affiliation(s)
- Babitha Haridas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David T Chuang
- Department of Neurology, Weill Cornell School of Medicine, New York, New York
| | - Maromi Nei
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sudden Unexpected Death in Epilepsy. Neurol Int 2022; 14:600-613. [PMID: 35893283 PMCID: PMC9326725 DOI: 10.3390/neurolint14030048] [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: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is a complex neurological condition with numerous etiologies and treatment options. In a subset of these patients, sudden unexpected death can occur, and to date, there are numerous explanations as to the pathophysiological mechanisms and how to mitigate these catastrophic outcomes. Approximately 2.3 million Americans have epilepsy, and nearly 150,000 people develop the condition each year. Sudden unexpected death in epilepsy (SUDEP) accounts for 2–18% of all epilepsy-related deaths and this is equivalent to one death in 1000 person-years of diagnosed epilepsy. It is more common in young adults aged 20–45. Seizures in the past year; the absence of terminal remission in the last five years; increased seizure frequency, particularly GTCS; and nocturnal seizures are the most potent modifiable risk factors for SUDEP. Patients not receiving any antiepileptic drug therapy are at higher risk of SUDEP. Patient education on medication compliance; care plans for seizure clusters (rescue medicines); epilepsy self-management programs; and lifestyle changes to avoid seizure-triggering factors, including avoiding excessive alcohol use and sleep deprivation, should be provided by health care providers. Continued research into SUDEP will hopefully lead to effective interventions to minimize occurrences. At present, aggressive control of epilepsy and enhanced education for individuals and the public are the most effective weapons for combating SUDEP. This narrative review focuses on updated information related to SUDEP epidemiology; pathophysiology; risk factor treatment options; and finally, a discussion of important clinical studies. We seek to encourage clinicians who care for patients with epilepsy to be aggressive in controlling seizure activity and diligent in their review of risk factors and education of patients and their families about SUDEP.
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Hamdy RM, Abdel-Tawab H, Abd Elaziz OH, Sobhy El attar R, Kotb FM. Evaluation of Heart Rate Variability Parameters During Awake and Sleep in Refractory and Controlled Epileptic Patients. Int J Gen Med 2022; 15:3865-3877. [PMID: 35422653 PMCID: PMC9004725 DOI: 10.2147/ijgm.s354895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Rehab M Hamdy
- Department of Cardiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
- Correspondence: Rehab M Hamdy, Department of Cardiology, Faculty for Medicine (for Girls), Al-Azhar University, Cairo, Egypt, Tel +201003022726, Email
| | - Hayam Abdel-Tawab
- Department of Neurology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Ola H Abd Elaziz
- Department of Cardiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Rasha Sobhy El attar
- Department of Neurology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Fatma M Kotb
- Department of Internal Medicine, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
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Hamdy RM, Elaziz OHA, El attar RS, Abdel-Tawab H, Kotb FM. Evaluation of QT dispersion in epileptic patients and its association with SUDEP risk. Epilepsy Res 2022; 180:106860. [DOI: 10.1016/j.eplepsyres.2022.106860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/06/2022] [Accepted: 01/16/2022] [Indexed: 11/03/2022]
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Shaker KK, Al Mahdawi AM, Hamdan FB. Interictal autonomic dysfunction in patients with epilepsy. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00422-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Abstract
Background
Autonomic nervous system (ANS) symptoms are frequently present in people with epilepsy (PwE). They are generally more prominent when they originate from the temporal lobe. We aim to investigate the alterations of autonomic functions during the interictal period in patient with temporal lobe epilepsy (TLE) and idiopathic generalized epilepsy (IGE) using heart-based tests, blood pressure (BP)-based tests and sympathetic skin response (SSR). Forty-eight PwE with disease duration ranging from 2 to 15 years and 51 healthy individuals were studied. Long-term electroencephalography (EEG) monitoring, the heart rate variability (HRV) during normal breathing, deep breathing, Valsalva maneuver and standing, BP responses during standing, to isometric hand grip and to mental arithmetic, and the SSR was recorded for all participants.
Results
31 patients with TLE and 17 with IGE showed lower RR-IV values during deep breathing, Valsalva maneuver and standing, but not during rest, impaired BP responses during standing, isometric hand grip, and mental arithmetic. Also, prolonged SSR latencies. Within PwE group, no difference was noticed between males and females, nor between the left and right temporal lobes.
Conclusion
Abnormal autonomic (sympathetic and parasympathetic) regulatory functions suggest that epilepsy may alter the autonomic function and this is not only in TLE but rather in IGE too. These autonomic changes are irrespective of the localization of epilepsy between the two hemispheres. The ANS changes in epileptic patients, particularly those with autonomic symptoms, confirm that electrophysiologic measures of autonomic function may be of value in preventing sudden unexpected death in epilepsy.
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You SM, Jo HJ, Cho BH, Song JY, Kim DY, Hwang YH, Shon YM, Seo DW, Kim IY. Comparing Ictal Cardiac Autonomic Changes in Patients with Frontal Lobe Epilepsy and Temporal Lobe Epilepsy by Ultra-Short-Term Heart Rate Variability Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:666. [PMID: 34203291 PMCID: PMC8304923 DOI: 10.3390/medicina57070666] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Abnormal epileptic discharges in the brain can affect the central brain regions that regulate autonomic activity and produce cardiac symptoms, either at onset or during propagation of a seizure. These autonomic alterations are related to cardiorespiratory disturbances, such as sudden unexpected death in epilepsy. This study aims to investigate the differences in cardiac autonomic function between patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE) using ultra-short-term heart rate variability (HRV) analysis around seizures. Materials and Methods: We analyzed electrocardiogram (ECG) data recorded during 309 seizures in 58 patients with epilepsy. Twelve patients with FLE and 46 patients with TLE were included in this study. We extracted the HRV parameters from the ECG signal before, during and after the ictal interval with ultra-short-term HRV analysis. We statistically compared the HRV parameters using an independent t-test in each interval to compare the differences between groups, and repeated measures analysis of variance was used to test the group differences in longitudinal changes in the HRV parameters. We performed the Tukey-Kramer multiple comparisons procedure as the post hoc test. Results: Among the HRV parameters, the mean interval between heartbeats (RRi), normalized low-frequency band power (LF) and LF/HF ratio were statistically different between the interval and epilepsy types in the t-test. Repeated measures ANOVA showed that the mean RRi and RMSSD were significantly different by epilepsy type, and the normalized LF and LF/HF ratio significantly interacted with the epilepsy type and interval. Conclusions: During the pre-ictal interval, TLE patients showed an elevation in sympathetic activity, while the FLE patients showed an apparent increase and decrease in sympathetic activity when entering and ending the ictal period, respectively. The TLE patients showed a maintained elevation of sympathetic and vagal activity in the pos-ictal interval. These differences in autonomic cardiac characteristics between FLE and TLE might be relevant to the ictal symptoms which eventually result in SUDEP.
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Affiliation(s)
- Sung-Min You
- Department of Biomedical Engineering, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea;
| | - Hyun-Jin Jo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Baek-Hwan Cho
- Medical AI Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea;
- Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo-Yeon Song
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Dong-Yeop Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Yoon-Ha Hwang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Young-Min Shon
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Dae-Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - In-Young Kim
- Department of Biomedical Engineering, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea;
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Akyüz E, Üner AK, Köklü B, Arulsamy A, Shaikh MF. Cardiorespiratory findings in epilepsy: A recent review on outcomes and pathophysiology. J Neurosci Res 2021; 99:2059-2073. [PMID: 34109651 DOI: 10.1002/jnr.24861] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 12/17/2022]
Abstract
Epilepsy is a debilitating disorder of uncontrollable recurrent seizures that occurs as a result of imbalances in the brain excitatory and inhibitory neuronal signals, that could stem from a range of functional and structural neuronal impairments. Globally, nearly 70 million people are negatively impacted by epilepsy and its comorbidities. One such comorbidity is the effect epilepsy has on the autonomic nervous system (ANS), which plays a role in the control of blood circulation, respiration and gastrointestinal function. These epilepsy-induced impairments in the circulatory and respiratory systems may contribute toward sudden unexpected death in epilepsy (SUDEP). Although, various hypotheses have been proposed regarding the role of epilepsy on ANS, the linking pathological mechanism still remains unclear. Channelopathies and seizure-induced damages in ANS-control brain structures were some of the causal/pathological candidates of cardiorespiratory comorbidities in epilepsy patients, especially in those who were drug resistant. However, emerging preclinical research suggest that neurotransmitter/receptor dysfunction and synaptic changes in the ANS may also contribute to the epilepsy-related autonomic disorders. Thus, pathological mechanisms of cardiorespiratory dysfunction should be elucidated by considering the modifications in anatomy and physiology of the autonomic system caused by seizures. In this regard, we present a comprehensive review of the current literature, both clinical and preclinical animal studies, on the cardiorespiratory findings in epilepsy and elucidate the possible pathological mechanisms of these findings, in hopes to prevent SUDEP especially in patients who are drug resistant.
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Affiliation(s)
- Enes Akyüz
- Department of Biophysics, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Arda Kaan Üner
- Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Betül Köklü
- Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Alina Arulsamy
- Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Mohd Farooq Shaikh
- Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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Szurhaj W, Leclancher A, Nica A, Périn B, Derambure P, Convers P, Mazzola L, Godet B, Faucanie M, Picot MC, De Jonckheere J. Cardiac Autonomic Dysfunction and Risk of Sudden Unexpected Death in Epilepsy. Neurology 2021; 96:e2619-e2626. [PMID: 33837114 DOI: 10.1212/wnl.0000000000011998] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/26/2021] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE We aimed to test whether patients who died of sudden unexpected death in epilepsy (SUDEP) had an abnormal cardiac autonomic response to sympathetic stimulation by hyperventilation. METHODS We conducted a retrospective, observational, case-control study of a group of patients who died of SUDEP and controls who were matched to the patients for epilepsy type, drug resistance, sex, age at EEG recording, age at onset of epilepsy, and duration of epilepsy. We analyzed the heart rate (HR) and HR variability (HRV) at rest and during and after hyperventilation performed during the patient's last EEG recording before SUDEP. In each group, changes over time in HRV indexes were analyzed with linear mixed models. RESULTS Twenty patients were included in each group. In the control group, the HR increased and the root mean square of successive RR-interval differences (RMSSD) decreased during the hyperventilation and then returned to the baseline values. In the SUDEP group, however, the HR and RMSSD did not change significantly during or after hyperventilation. A difference in HR between the end of the hyperventilation and 4 minutes after its end discriminated well between patients with SUDEP and control patients (area under the receiver operating characteristic curve 0.870, sensitivity 85%, specificity 75%). CONCLUSION Most of patients with subsequent SUDEP have an abnormal cardiac autonomic response to sympathetic stimulation through hyperventilation. An index reflecting the change in HR on hyperventilation might be predictive of the risk of SUDEP and could be used to select patients at risk of SUDEP for inclusion in trials assessing protective measures.
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Affiliation(s)
- William Szurhaj
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France.
| | - Alexandre Leclancher
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Anca Nica
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Bertille Périn
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Philippe Derambure
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Philippe Convers
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Laure Mazzola
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Bertrand Godet
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Marie Faucanie
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Marie-Christine Picot
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
| | - Julien De Jonckheere
- From the Department of Clinical Neurophysiology (W.S., A.L., B.P.), Amiens University Medical Center; Equipe Chimere UR7516-Université Picardie Jules Verne (W.Z.), Amiens; Neurology Department (A.N.), Rennes University Hospital, CIC 1414, LTSI, INSERM U1099; Department of Clinical Neurophysiology (P.D.)and INSERM CIC-IT 1403 (J.D.j.), Lille University Medical Center; Neurology Department (P.C., L.M.), University Hospital, St Etienne; INSERM U 1028 (L.M.), CNRS UMR, ''Central Integration of Pain'' Group, Lyon Neuroscience Research Center; Department of Clinical Neurophysiology (B.G.), Limoges University Medical Center; and Unité de Recherche Clinique et Epidémiologie (Département Information Médicale) (M.F., M.-C.P.), CHU Montpellier, and INSERM (M.-C.P.), Centre d'Investigation Clinique 1411, Université Montpellier, France
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Deli A, Huang YG, Toynbee M, Towle S, Adcock JE, Bajorek T, Okai D, Sen A. Distinguishing psychogenic nonepileptic, mixed, and epileptic seizures using systemic measures and reported experiences. Epilepsy Behav 2021; 116:107684. [PMID: 33545648 DOI: 10.1016/j.yebeh.2020.107684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/08/2020] [Accepted: 11/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Our primary objective was to better discern features that can differentiate people with 'mixed' symptomatology from those who experience epileptic seizures (ES) or functional/psychogenic nonepileptic seizures (PNES) alone, in a population of patients referred for video-telemetry. We wished to see if we could establish the prevalence of PNES in this population of interest as well as compare both objective (e.g. videotelemetry reports and heart rate measurements) and subjective, patient-centered measures (reported symptoms and experiences). METHODS Data were sourced from a database of all video-telemetry patients admitted to the John Radcliffe Hospital (Oxford, UK) between 1st Jan 2014 and 31st Jan 2016; video-electroencephalogram (vEEG) reports for the above patients; neurology clinic letters; multidisciplinary Team (MDT) reports; psychology assessments and patient notes for all vEEG patients referred for surgical work up. Mixed cases with a dual ES/PNES diagnosis were carefully evaluated again by the Consultant Neurologist under whose care each respective patient was, through case-by-case evaluation of EEG and telemetry reports. We compared mean heart rate during attacks captured on vEEG, number of physical symptoms reported, episode length, and postictal confusion between the three groups (ES; PNES; ES and PNES (mixed)). We evaluated the groups in terms of demographic and psychological parameters as well as prescription of anti-seizure medication. Pearson correlation significance was examined at 95% level of significance for p-values corrected for multiple comparisons. RESULTS Overall, mixed cases reported experiencing a significantly lower number of physical symptoms compared to PNES cases (p = 0.018). The heart rate of PNES cases was significantly lower than that of mixed cases during the attacks (p = 0.003). ES patients exhibited the highest heart rate of all three groups and a greater degree of postictal confusion (adjusted p = 0.003 and p < 0.001, respectively) compared to those with PNES. There was no statistically significant difference in episode length between mixed and ES cases, while PNES patients had significantly longer episode duration (p = 0.021) compared to the mixed group. We noted that 81.6% of PNES patients were taking at least one anti-seizure medication. CONCLUSION Patients with mixed seizures seem to be part of a spectrum between ES and PNES cases. Mixed cases are more similar to the ES group with regard to episode length and number of symptoms reported. In the PNES cohort, we found an over-reporting of ictal symptoms (e.g. palpitations, diaphoresis) disproportionate to recorded heart rate, which is lower in PNES than in epileptic attacks. This seems consistent with PNES cases experiencing a degree of impaired interoceptive processing, as part of a functional disorder spectrum. We noted that there was tendency for overmedication in the PNES group. The need for 'de-prescribing' should be addressed with measures that include better liaison with the community care team. With regard to potential autonomic dysregulation in the mixed cases, it might be interesting to see if vagus nerve stimulation could be accompanied by normalization of cardiovascular physiology parameters for people with both epileptic and psychogenic nonepileptic seizures.
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Affiliation(s)
- Alceste Deli
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, UK
| | - Yi-Ge Huang
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Mark Toynbee
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Susan Towle
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Jane E Adcock
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Tomasz Bajorek
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - David Okai
- Institute of Psychiatry, Psychology and Neurosciences, Section of Cognitive Neuropsychiatry, King's College London, London, UK
| | - Arjune Sen
- Oxford Epilepsy Research Group, NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK.
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Singh J, Lanzarini E, Santosh P. Autonomic Characteristics of Sudden Unexpected Death in Epilepsy in Children-A Systematic Review of Studies and Their Relevance to the Management of Epilepsy in Rett Syndrome. Front Neurol 2021; 11:632510. [PMID: 33613425 PMCID: PMC7892970 DOI: 10.3389/fneur.2020.632510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/28/2020] [Indexed: 01/21/2023] Open
Abstract
Aim: To systematically identify and critically appraise studies that investigate the autonomic characteristics of Sudden Unexpected Death in Epilepsy (SUDEP) in the pediatric population. We also wanted to explore how this information would be relevant to the management of epilepsy in patients with Rett Syndrome. Method: Using PRISMA guidelines, a systematic review of PubMed, Scopus, Cochrane, PsycINFO, Embase, and Web of Science databases was performed to identify eligible studies. After extracting data from the included studies, a thematic analysis was undertaken to identify emerging themes. A quality appraisal was also done to assess the quality of the included studies. Results: The systematic search revealed 41 records, and 15 full-text articles on the autonomic characteristics of SUDEP in children were included in the final analysis. Following thematic analysis, three themes were identified (I) modulation in sympathovagal tone, (II) pre- and post-ictal autonomic changes, and (III) other markers of autonomic dysregulation in children with epilepsy. Modulation in sympathovagal tone emerged as the theme with the highest frequency followed by pre- and post-ictal autonomic changes. While the themes provide additional insight into the management of epilepsy in the Rett Syndrome population, the quality of evidence concerning the autonomic characteristics of SUDEP in the pediatric population was low and underscores the importance of much needed research in this area. Conclusion: The mechanism of SUDEP in the pediatric population is complex and involves an interplay between several components of the autonomic nervous system. While direct clinical inferences regarding pediatric SUDEP could not be made, the thematic analysis does suggest that in vulnerable populations such as Rett Syndrome, where there is already a pervasive autonomic dysregulation, pro-active surveillance of the autonomic profile in this patient group would be useful to better manage epilepsy and reduce the SUDEP risk.
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Affiliation(s)
- Jatinder Singh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Evamaria Lanzarini
- Child and Adolescent Neuropsychiatry Unit, Infermi Hospital, Rimini, Italy
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases, South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Centre for Personalised Medicine in Rett Syndrome, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Autonomic functions in focal epilepsy: A comparison between lacosamide and carbamazepine monotherapy. J Neurol Sci 2020; 418:117095. [DOI: 10.1016/j.jns.2020.117095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 11/22/2022]
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Mishra R, Florez-Perdomo WA, Shrivatava A, Chouksey P, Raj S, Moscote-Salazar LR, Rahman MM, Sutar R, Agrawal A. Role of Music Therapy in Traumatic Brain Injury: A Systematic Review and Meta-analysis. World Neurosurg 2020; 146:197-204. [PMID: 33130286 DOI: 10.1016/j.wneu.2020.10.130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/24/2020] [Accepted: 10/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Music therapy has promising results in improving rehabilitation outcomes of patients with various neurologic disorders; however, its effectiveness in patients with traumatic brain injury (TBI) is not clear. METHODS A search that compared the effect of music therapy as rehabilitation to controls in motor and cognitive outcomes in patients with TBI was carried out. The outcome of interest were gait velocity, stride length, and cadence to determine the motor outcome. Memory and executive function were the main cognitive outcome measures assessed. Two authors independently abstracted data using a data collection form. Results from the studies were then pooled when appropriate for the meta-analysis. RESULTS Of 102 studies, 6 studies were identified for systematic review and meta-analysis after inclusion and exclusion criteria. The effect of music therapy had a pooled mean difference in improvement in gait velocity by 12.29 cm/second (95% confidence interval 2.31-22.27;), cadence by 7.19 steps/minute (95% confidence interval -25.35 to 39.73;), and stride length by 0.19 meters (95% confidence interval 0.13-0.12;). No serious side effects were noticed, however, one of the studies reported a decrease in memory function after music therapy. CONCLUSIONS Pooled results from 6 studies demonstrated statistically significant improvement in the stride length and executive function outcome in patients with TBI after music therapy rehabilitation. The improvement effect on cadence and gait velocity was not statistically significant and no significant effect of music therapy was found on memory in these patients.
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Affiliation(s)
- Rakesh Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - William Andres Florez-Perdomo
- Medicina General-Universidad Surcolombiana, Medico Investigador Concejo Latinoamericano de Neurointensivismo-CLaNi, Clinica Sahagún IPS SA Columbia, Cartegena, Columbia
| | - Adesh Shrivatava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Pradeep Chouksey
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Md Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent, Medical College, Dhaka, Bangladesh
| | - Roshan Sutar
- Psychosomatic Medicine Clinic, Department of Psychiatry, All India Institute of Medical Sciences, Bhopal, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India.
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20
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21
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Okanari K, Maruyama S, Suzuki H, Shibata T, Pulcine E, Donner EJ, Otsubo H. Autonomic dysregulation in children with epilepsy with postictal generalized EEG suppression following generalized convulsive seizures. Epilepsy Behav 2020; 102:106688. [PMID: 31805503 DOI: 10.1016/j.yebeh.2019.106688] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/17/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Postictal generalized electroencephalographic suppression (PGES) has been associated with sudden unexpected death in epilepsy (SUDEP) in adults. Decreased heart rate variability (HRV) is one clinical marker of SUDEP in adults with epilepsy. The objective of this study was to analyze the characteristics of HRV associated with generalized convulsive seizures (GCS) ± PGES in children. METHODS Nine hundred and seventy-seven consecutive children who underwent prolonged scalp video-EEG (vEEG) and 1-lead electrocardiogram (ECG) monitoring at the Hospital for Sick Children, Toronto, Ontario, Canada were reviewed retrospectively from 2009 to 2011. Thirty-five children had GCS captured during their vEEG with or without PGES and met inclusion criteria. Children were subdivided into three age groups and compared with age-matched controls: 3-6 years; 7-12 years; and 13-18 years. Interictal HRV was measured at 5 min during N2 sleep. Preictal HRV was measured at 1 h prior to GCS onset, and postictal HRV was measured at 3 min post-GCS cessation. Low frequency (LF: ms2, 0.04-0.15 Hz) and high frequency (HF: ms2, 0.15-0.4 Hz) bands of heart rate oscillations were analyzed during the interictal and preictal periods. The root mean square of successive differences (RMSSDs) was analyzed during the following time points: interictal; preictal; and postictal. RESULTS Thirty-five children had GCS: 18 children with PGES [3-6 years (n = 2); 7-12 years (n = 6); 13-18 years (n = 10)] and 17 children without PGES [3-6 years (n = 6); 7-12 years (n = 5); 13-18 years (n = 6)]. Seventeen additional age-matched controls were identified [3-6 years (n = 3); 7-12 years (n = 5); 13-18 years (n = 9)]. Seventy-four GCS were captured consisting of 36 GCS + PGES and 38 GCS - PGES. There was no difference of interictal HRV among children with GCS ± PGES and controls. The preictal LF and HF in 36 GCS + PGES were significantly higher compared with 38 GCS - PGES (p < 0.01). The postictal RMSSD in 36 GCS + PGES was significantly higher compared with 38 GCS - PGES (p < 0.01). The pre- to postictal RMSSD change was significantly lower in children with GCS + PGES than in those with GCS - PGES (p = 0.035). CONCLUSIONS In summary, the preictal HRV in GCS + PGES was significantly higher than in children with GCS - PGES. The higher remaining postictal RMSSD in children with GCS + PGES is a potential indicator of autonomic dysregulation. In certain children with epilepsy, autonomic dysregulation may contribute to poor recovery from a GCS with subsequent PGES, thereby contributing to SUDEP. Heart rate variability and autonomic regulation in children with epilepsy should be further studied prospectively in order to better understand the mechanism by which PGES may lead to SUDEP.
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Affiliation(s)
- Kazuo Okanari
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shinsuke Maruyama
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroharu Suzuki
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Takashi Shibata
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Pulcine
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth J Donner
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hiroshi Otsubo
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Li MCH, O'Brien TJ, Todaro M, Powell KL. Acquired cardiac channelopathies in epilepsy: Evidence, mechanisms, and clinical significance. Epilepsia 2019; 60:1753-1767. [PMID: 31353444 DOI: 10.1111/epi.16301] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 07/07/2019] [Accepted: 07/07/2019] [Indexed: 12/13/2022]
Abstract
There is growing evidence that cardiac dysfunction in patients with chronic epilepsy could play a pathogenic role in sudden unexpected death in epilepsy (SUDEP). Recent animal studies have revealed that epilepsy secondarily alters the expression of cardiac ion channels alongside abnormal cardiac electrophysiology and remodeling. These molecular findings represent novel evidence for an acquired cardiac channelopathy in epilepsy, distinct from inherited ion channels mutations associated with cardiocerebral phenotypes. Specifically, seizure activity has been shown to alter the messenger RNA (mRNA) and protein expression of voltage-gated sodium channels (Nav 1.1, Nav 1.5), voltage-gated potassium channels (Kv 4.2, Kv 4.3), sodium-calcium exchangers (NCX1), and nonspecific cation-conducting channels (HCN2, HCN4). The pathophysiology may involve autonomic dysfunction and structural cardiac disease, as both are independently associated with epilepsy and ion channel dysregulation. Indeed, in vivo and in vitro studies of cardiac pathology reveal a complex network of signaling pathways and transcription factors regulating ion channel expression in the setting of sympathetic overactivity, cardiac failure, and hypertrophy. Other mechanisms such as circulating inflammatory mediators or exogenous effects of antiepileptic medications lack evidence. Moreover, an acquired cardiac channelopathy may underlie the electrophysiologic cardiac abnormalities seen in chronic epilepsy, potentially contributing to the increased risk of malignant arrhythmias and sudden death. Therefore, further investigation is necessary to establish whether cardiac ion channel dysregulation similarly occurs in patients with epilepsy, and to characterize any pathogenic relationship with SUDEP.
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Affiliation(s)
- Michael C H Li
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Marian Todaro
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kim L Powell
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Spectral entropy indicates electrophysiological and hemodynamic changes in drug-resistant epilepsy - A multimodal MREG study. NEUROIMAGE-CLINICAL 2019; 22:101763. [PMID: 30927607 PMCID: PMC6444290 DOI: 10.1016/j.nicl.2019.101763] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 02/01/2019] [Accepted: 03/10/2019] [Indexed: 12/20/2022]
Abstract
Objective Epilepsy causes measurable irregularity over a range of brain signal frequencies, as well as autonomic nervous system functions that modulate heart and respiratory rate variability. Imaging dynamic neuronal signals utilizing simultaneously acquired ultra-fast 10 Hz magnetic resonance encephalography (MREG), direct current electroencephalography (DC-EEG), and near-infrared spectroscopy (NIRS) can provide a more comprehensive picture of human brain function. Spectral entropy (SE) is a nonlinear method to summarize signal power irregularity over measured frequencies. SE was used as a joint measure to study whether spectral signal irregularity over a range of brain signal frequencies based on synchronous multimodal brain signals could provide new insights in the neural underpinnings of epileptiform activity. Methods Ten patients with focal drug-resistant epilepsy (DRE) and ten healthy controls (HC) were scanned with 10 Hz MREG sequence in combination with EEG, NIRS (measuring oxygenated, deoxygenated, and total hemoglobin: HbO, Hb, and HbT, respectively), and cardiorespiratory signals. After pre-processing, voxelwise SEMREG was estimated from MREG data. Different neurophysiological and physiological subfrequency band signals were further estimated from MREG, DC-EEG, and NIRS: fullband (0–5 Hz, FB), near FB (0.08–5 Hz, NFB), brain pulsations in very-low (0.009–0.08 Hz, VLFP), respiratory (0.12–0.4 Hz, RFP), and cardiac (0.7–1.6 Hz, CFP) frequency bands. Global dynamic fluctuations in MREG and NIRS were analyzed in windows of 2 min with 50% overlap. Results Right thalamus, cingulate gyrus, inferior frontal gyrus, and frontal pole showed significantly higher SEMREG in DRE patients compared to HC. In DRE patients, SE of cortical Hb was significantly reduced in FB (p = .045), NFB (p = .017), and CFP (p = .038), while both HbO and HbT were significantly reduced in RFP (p = .038, p = .045, respectively). Dynamic SE of HbT was reduced in DRE patients in RFP during minutes 2 to 6. Fitting to the frontal MREG and NIRS results, DRE patients showed a significant increase in SEEEG in FB in fronto-central and parieto-occipital regions, in VLFP in parieto-central region, accompanied with a significant decrease in RFP in frontal pole and parietal and occipital (O2, Oz) regions. Conclusion This is the first study to show altered spectral entropy from synchronous MREG, EEG, and NIRS in DRE patients. Higher SEMREG in DRE patients in anterior cingulate gyrus together with SEEEG and SENIRS results in 0.12–0.4 Hz can be linked to altered parasympathetic function and respiratory pulsations in the brain. Higher SEMREG in thalamus in DRE patients is connected to disturbances in anatomical and functional connections in epilepsy. Findings suggest that spectral irregularity of both electrophysiological and hemodynamic signals are altered in specific way depending on the physiological frequency range. Simultaneous imaging methods indicate spectral irregularity in neurovascular and electrophysiological brain pulsations in DRE. Altered spectral entropy in EEG, NIRS and BOLD indicate dysfunctional brain pulsations in respiratory frequency in epilepsy. Spectral irregularity (0-5 Hz) of BOLD in right thalamus supports previous structural and functional findings in epilepsy.
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24
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Manolis TA, Manolis AA, Melita H, Manolis AS. Sudden unexpected death in epilepsy: The neuro-cardio-respiratory connection. Seizure 2019; 64:65-73. [DOI: 10.1016/j.seizure.2018.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/09/2018] [Accepted: 12/13/2018] [Indexed: 12/21/2022] Open
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Aicua-Rapun I, André P, Novy J. Closed-loop Neuropharmacology for Epilepsy: Distant Dream or Future Reality? Curr Neuropharmacol 2019; 17:447-458. [PMID: 29521237 PMCID: PMC6520584 DOI: 10.2174/1570159x16666180308154646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/10/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
Epilepsy is considered the most frequent severe neurological condition but most patients treated with medication become seizure free. The management of treatment, however, is highly empirical, mainly relying on observation. A closed-loop therapy for epilepsy would be very valuable for more efficient treatment regimens. Here we discuss monitoring treatment (therapeutic drug monitoring) and the potential developments in this field, as well as providing a review of potential biomarkers that could be used to monitor the disease activity. Finally, we consider the pharmacogenetic input in epilepsy treatment.
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Affiliation(s)
- Irene Aicua-Rapun
- Address correspondence to this author at the Department of Neuroscience, Neurology service. University Hospital of Lausanne BH07, Faculty of Biology and Medicine, University of Lausanne. Rue du Bugnon 46 CH 1011, Lausanne, Switzerland; Tel/Fax: +41213144552, +41213141290;, E-mail:
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26
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Özer G. Autonomic Dysfunction in Epileptic Patients. JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2018. [DOI: 10.5799/jcei.433809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Hirfanoglu T, Serdaroglu A, Cetin I, Kurt G, Capraz IY, Ekici F, Arhan E, Bilir E. Effects of vagus nerve stimulation on heart rate variability in children with epilepsy. Epilepsy Behav 2018; 81:33-40. [PMID: 29462779 DOI: 10.1016/j.yebeh.2018.01.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/22/2018] [Accepted: 01/26/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to evaluate the effects of vagus nerve stimulation (VNS) on heart rate variability (HRV) in children with epilepsy. METHODS The subgroups of HRV, namely time domain (Standard deviation of NN interval (SDNN), SDNN index, Standard deviation of the averages of NN intervals (SDANN), Root mean square of successive differences (RMMSD), Adjacent NN intervals differing by more than 50 ms in the entire recording divided by the total number of all NN intervals (PNN50), triangular index) and frequency domain (Low-frequency (LF), High-frequency (HF), LF/HF), were investigated in 20 pediatric patients before and after 6 and 12months of VNS treatment during day and night by comparing their data with those of 20 control subjects. In addition, subgroups of age, epilepsy duration and localization, and antiepileptic drugs (AEDs) were also evaluated if they had further effects on basal HRV levels. RESULTS Increased heart rates (HRs); decreased SDNN, SDANN, RMMSD, and PNN50; and increased LF/HF ratios were identified before VNS therapy (p<0.05). Even though remarkable improvement was seen after 6months of VNS treatment (p<0.05), no further changes were observed in 12-month compared with 6-month levels (p>0.05) in all parameters, still even significantly lower than those of controls (p<0.05). Longer duration of epilepsy and localization of epileptic focus, such as in the temporal lobe, were also found to further contribute to diminished basal HRV levels (p<0.05). CONCLUSION The cardiovascular system is under deep sympathetic influence in children with epilepsy. Although VNS seems to provide a substantial improvement by achieving increased parasympathetic effects in short-term therapy, the levels were still lower than those of healthy children after either short- or long-term therapy. Therefore, impaired cardiovascular autonomic regulation may be associated with the epileptic process itself as well as with the contribution of some additional factors. Overall, different aspects such as age, epilepsy duration, epileptic focus, seizure frequency, and AEDs should also be considered for their further possible effects on HRV during VNS therapy.
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Affiliation(s)
- Tugba Hirfanoglu
- Gazi University School of Medicine, Department of Pediatric Neurology, Ankara, Turkey.
| | - Ayse Serdaroglu
- Gazi University School of Medicine, Department of Pediatric Neurology, Ankara, Turkey
| | - Ilker Cetin
- Ankara Children's Hematology Oncology Training and Research Hospital, Department of Pediatric Cardiology, Ankara, Turkey
| | - Gokhan Kurt
- Gazi University School of Medicine, Department of Neurosurgery, Ankara, Turkey
| | - Irem Y Capraz
- Gazi University School of Medicine, Department of Neurology, Ankara, Turkey
| | - Filiz Ekici
- Akdeniz University School of Medicine, Department of Pediatric Cardiology, Antalya, Turkey
| | - Ebru Arhan
- Gazi University School of Medicine, Department of Pediatric Neurology, Ankara, Turkey
| | - Erhan Bilir
- Gazi University School of Medicine, Department of Neurology, Ankara, Turkey
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Choudhary N, Deepak KK, Chandra PS, Bhatia S, Sagar R, Jaryal AK, Pandey RM, Tripathi M. Comparison of Autonomic Function before and after Surgical Intervention in Patients with Temporal Lobe Epilepsy. J Epilepsy Res 2017; 7:89-98. [PMID: 29344466 PMCID: PMC5767494 DOI: 10.14581/jer.17014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/14/2017] [Indexed: 11/22/2022] Open
Abstract
Background and Purpose Refractory temporal lobe epilepsy (TLE) is commonly associated with imbalances in cardiovascular (CV) parasympathetic and sympathetic functions, which are treated using TLE surgery. We investigated the effect of hemispheric lateralization of seizure foci on autonomic CV functions before and after TLE surgery. Methods The study was conducted on patients with left TLE (LTLE, n = 23) and right TLE (RTLE, n = 30) undergoing unilateral TLE surgery. To assess the autonomic CV functions, changes in the heart rate (ΔHR) and blood pressure (BP) were measured using a standardized battery of autonomic reactivity tests before surgery and at 3 and 6 months after surgery. Results Before surgery, ΔHR and the expiration to inspiration ratio (E:I) during the deep breathing test were higher in the LTLE group than in the RTLE group (both p < 0.001), but both outcomes were comparable between the groups at 3 and 6 months. ΔHR decreased at 3 and 6 months (p < 0.001 and 0.01, respectively) compared with preoperative values. The E:I at 3 months in the LTLE group was lower (p = 0.04) than the preoperative values. Decrease in systolic BP during the head-up tilt test was greater in the LTLE group than in the RTLE group (p = 0.002) before surgery. The maximum increase in diastolic BP during the cold pressor test was lower in the RTLE group at 6 months than that before surgery (p = 0.001) and in the LTLE group (p = 0.002). Conclusions We found that hemispheric lateralization of seizure foci in the temporal lobe had a differential effect on autonomic CV functions before surgery. Before surgery, parasympathetic reactivity was higher in the LTLE group, and sympathetic reactivity was higher in the RTLE group. After surgery, autonomic CV functions were comparable between the groups, suggesting that TLE surgery stabilizes autonomic CV functions.
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Affiliation(s)
- Navita Choudhary
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kishore K Deepak
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Poodipedi S Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shalini Bhatia
- Department of Research Support, A.T.Still University, Kirksville, MO, USA
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok K Jaryal
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra M Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Abstract
People with epilepsy have increased risk of premature death, and their life expectancy may reduce by 2-10 yr. Population- and hospital-based studies have shown that the excess mortality in epilepsy is not entirely explained by deaths directly attributable to epilepsy such as accidents and drowning during a seizure. It is also significantly contributed by deaths from other causes such as cardiac deaths, deaths due to malignancies and other causes. It had recently been recognized that sudden unexpected deaths in epilepsy (SUDEP) contributed to a small yet important proportion of mortality in epilepsy. SUDEPs are deaths (witnessed or unwitnessed) unrelated to trauma, drowning or status epilepticus and not attributable to any specific medical conditions. Several factors related to epilepsy and drug therapy have been found to be associated with higher risk of SUDEP.
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Affiliation(s)
- Shishir Nagesh Duble
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
| | - Sanjeev V Thomas
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram, India
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30
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Allen LA, Harper RM, Kumar R, Guye M, Ogren JA, Lhatoo SD, Lemieux L, Scott CA, Vos SB, Rani S, Diehl B. Dysfunctional Brain Networking among Autonomic Regulatory Structures in Temporal Lobe Epilepsy Patients at High Risk of Sudden Unexpected Death in Epilepsy. Front Neurol 2017; 8:544. [PMID: 29085330 PMCID: PMC5650686 DOI: 10.3389/fneur.2017.00544] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/27/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sudden unexpected death in epilepsy (SUDEP) is common among young people with epilepsy. Individuals who are at high risk of SUDEP exhibit regional brain structural and functional connectivity (FC) alterations compared with low-risk patients. However, less is known about network-based FC differences among critical cortical and subcortical autonomic regulatory brain structures in temporal lobe epilepsy (TLE) patients at high risk of SUDEP. METHODS 32 TLE patients were risk-stratified according to the following clinical criteria: age of epilepsy onset, duration of epilepsy, frequency of generalized tonic-clonic seizures, and presence of nocturnal seizures, resulting in 14 high-risk and 18 low-risk cases. Resting-state functional magnetic resonance imaging (rs-fMRI) signal time courses were extracted from 11 bilateral cortical and subcortical brain regions involved in autonomic and other regulatory processes. After computing all pairwise correlations, FC matrices were analyzed using the network-based statistic. FC strength among the 11 brain regions was compared between the high- and low-risk patients. Increases and decreases in FC were sought, using high-risk > low-risk and low-risk > high-risk contrasts (with covariates age, gender, lateralization of epilepsy, and presence of hippocampal sclerosis). RESULTS High-risk TLE patients showed a subnetwork with significantly reduced FC (t = 2.5, p = 0.029) involving the thalamus, brain stem, anterior cingulate, putamen and amygdala, and a second subnetwork with significantly elevated FC (t = 2.1, p = 0.031), which extended to medial/orbital frontal cortex, insula, hippocampus, amygdala, subcallosal cortex, brain stem, thalamus, caudate, and putamen. CONCLUSION TLE patients at high risk of SUDEP showed widespread FC differences between key autonomic regulatory brain regions compared to those at low risk. The altered FC revealed here may help to shed light on the functional correlates of autonomic disturbances in epilepsy and mechanisms involved in SUDEP. Furthermore, these findings represent possible objective biomarkers which could help to identify high-risk patients and enhance SUDEP risk stratification via the use of non-invasive neuroimaging, which would require validation in larger cohorts, with extension to patients with other epilepsies and subjects who succumb to SUDEP.
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Affiliation(s)
- Luke A Allen
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Ronald M Harper
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States
| | - Rajesh Kumar
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States.,Department of Anaesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Department of Bioengineering, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Maxime Guye
- Aix Marseille University, CNRS, CRMBM UMR 7339, Marseille, France
| | - Jennifer A Ogren
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Samden D Lhatoo
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Epilepsy Centre, Neurological Institute, University Hospitals Case Medical Centre, Cleveland, OH, United States
| | - Louis Lemieux
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom
| | - Catherine A Scott
- Institute of Neurology, University College London, London, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Sjoerd B Vos
- Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Translational Imaging Group, University College London, London, United Kingdom
| | - Sandhya Rani
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Epilepsy Centre, Neurological Institute, University Hospitals Case Medical Centre, Cleveland, OH, United States
| | - Beate Diehl
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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31
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Lee DH. Cardiac Complications in Patients Admitted to the Neuro-Intensive Care Unit. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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32
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Baysal-Kirac L, Serbest NG, Şahin E, Dede HÖ, Gürses C, Gökyiğit A, Bebek N, Bilge AK, Baykan B. Analysis of heart rate variability and risk factors for SUDEP in patients with drug-resistant epilepsy. Epilepsy Behav 2017; 71:60-64. [PMID: 28549245 DOI: 10.1016/j.yebeh.2017.04.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/08/2017] [Accepted: 04/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac problems have been suggested as causes of sudden unexpected death in epilepsy (SUDEP). Our aim was to investigate possible associations of cardiac autonomic functions based on heart rate variability (HRV) parameters with risk factors of SUDEP in patients with drug-resistant epilepsy. METHODS Forty-seven patients with drug-resistant seizures and 45 healthy control subjects were enrolled in the study. Interictal time domain parameters of HRV were evaluated with 24-hour Holter recordings. Potential SUDEP risk in patients with epilepsy was estimated using an inventory of seven validated SUDEP risk factors (The SUDEP-7 inventory). RESULTS When compared with the healthy controls, all time domain measures (SDNN-24, SDNN-index, SDANN-index, RMSSD and pNN50) were significantly suppressed in the patient group. Scores of the SUDEP-7 inventory ranged from 1 to 9 with a median 4 out of a maximum possible risk score of 10. Maximum heart rate value in 24-hour Holter recordings and epilepsy duration were correlated with the SUDEP-7 scores (r=0.3, p=0.03). We found no significant association with HRV measures and SUDEP-7 risk factors. One patient diagnosed with Dravet syndrome died of SUDEP, which was autopsy confirmed; his SUDEP-7 inventory score was 7, HRV measures were significantly diminished, and his maximum heart rate (HR) was 208beats/min (maximum HR is between 104 and 188beats/min in normal subjects). CONCLUSION Patients with drug-resistant epilepsy present with significantly lower HRV measures, which may increase the risk for sudden cardiac death. Increased heart rate and diminished HRV measures may constitute one of the possible mechanisms underlying SUDEP and should be diagnosed in patients with epilepsy.
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Affiliation(s)
- Leyla Baysal-Kirac
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nail Güven Serbest
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Erdi Şahin
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Hava Özlem Dede
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Candan Gürses
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ayşen Gökyiğit
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nerses Bebek
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ahmet Kaya Bilge
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
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Yuen AWC, Sander JW. Can natural ways to stimulate the vagus nerve improve seizure control? Epilepsy Behav 2017; 67:105-110. [PMID: 28152451 DOI: 10.1016/j.yebeh.2016.10.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/29/2016] [Indexed: 02/07/2023]
Abstract
The vagus nerve (VN) is the longest cranial nerve, innervating the neck, thorax and abdomen, with afferent fibers transmitting a range of interoceptive stimuli and efferent fibres to somatic structures and autonomic preganglions. Over the last few decades, electrical stimulation of the VN using implanted devices (VNS) has been developed leading to its approval for the treatment of epilepsy and depression. More recently, non-invasive devices to stimulation the VN have been developed. The VN has many functions and the activity that is most amenable to assessment is its effect in controlling the cardiac rhythm. This can be easily assessed by measuring heart rate variability (HRV). Decreased HRV is a result of poorer vagal parasympathetic tone and is associated with a wide range of ill health conditions including a higher risk of early mortality. People with epilepsy, particularly those with poorly controlled seizures, have been shown to have impaired parasympathetic tone. So, might natural ways to stimulate the VN, shown to improve parasympathetic tone as indicated by increased HRV, improve seizure control? There are numerous natural ways that have been shown to stimulate the VN, improving HRV and hence parasympathetic tone. These natural ways fall mainly into 3 categories - stress reduction, exercise, and nutrition. Though the natural ways to stimulate the VN have been shown to increase HRV, they have not been shown to reduce seizures. The exception is listening to Mozart's music, which has been shown to increase parasympathetic tone and decrease seizures. Clearly much more work is required to examine the effect of the various ways to increase HRV on seizure occurrence.
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Affiliation(s)
- Alan W C Yuen
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, WC1N 3BG London, UK; Epilepsy Society, Chalfont St Peter, UK.
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, WC1N 3BG London, UK; SEIN-Epilepsy Institute in the Netherlands Foundation, Achterweg 5, 2103 SW Heemstede, The Netherlands; Epilepsy Society, Chalfont St Peter, UK
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Tényi D, Gyimesi C, Kupó P, Horváth R, Bóné B, Barsi P, Kovács N, Simor T, Siegler Z, Környei L, Fogarasi A, Janszky J. Ictal asystole: A systematic review. Epilepsia 2016; 58:356-362. [DOI: 10.1111/epi.13644] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Dalma Tényi
- Department of Neurology; University of Pécs; Pécs Hungary
| | - Csilla Gyimesi
- Department of Neurology; University of Pécs; Pécs Hungary
| | - Péter Kupó
- Heart Institute; University of Pécs; Pécs Hungary
| | - Réka Horváth
- Department of Neurology; University of Pécs; Pécs Hungary
| | - Beáta Bóné
- Department of Neurology; University of Pécs; Pécs Hungary
| | - Péter Barsi
- MR Research Center; Semmelweis University; Budapest Hungary
| | - Norbert Kovács
- Department of Neurology; University of Pécs; Pécs Hungary
- PTE-MTA Clinical Neuroscience MR Research Group; Budapest Hungary
| | - Tamás Simor
- Heart Institute; University of Pécs; Pécs Hungary
| | - Zsuzsa Siegler
- Epilepsy Center; Bethesda Children's Hospital; Budapest Hungary
| | - László Környei
- Gottsegen György Hungarian Institute of Cardiology; Budapest Hungary
| | - András Fogarasi
- Epilepsy Center; Bethesda Children's Hospital; Budapest Hungary
| | - József Janszky
- Department of Neurology; University of Pécs; Pécs Hungary
- PTE-MTA Clinical Neuroscience MR Research Group; Budapest Hungary
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Pansani AP, Xavier CH, de Castro CH, Scorza FA, Colugnati DB. Could the retrotrapezoid nucleus neurons tell us something about SUDEP? Epilepsy Behav 2016; 61:86-87. [PMID: 27337159 DOI: 10.1016/j.yebeh.2016.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Aline P Pansani
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Carlos H Xavier
- Laboratório de Fisiologia e Terapêutica Cardiovascular, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Carlos Henrique de Castro
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
| | - Fulvio A Scorza
- Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - Diego B Colugnati
- Laboratório Integrado de Fisiopatologia Cardiovascular e Neurológica, Departamento de Ciências Fisiológicas, ICB, Universidade Federal de Goiás, GO, Brazil
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Kilinc O, Cincin A, Pehlivan A, Midi I, Kepez A, Agan K. Assessment of Time and Frequency Domain Parameters of Heart Rate Variability and Interictal Cardiac Rhythm Abnormalities in Drug-naïve Patients with Idiopathic Generalized Epilepsy. J Epilepsy Res 2016; 6:22-7. [PMID: 27390676 PMCID: PMC4933677 DOI: 10.14581/jer.16004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/19/2016] [Indexed: 01/11/2023] Open
Abstract
Background and Purpose: Epilepsy is a disease known to occur with autonomous phenomenons. Earlier studies indicate decreased heart rate variability (HRV) during ictal and interictal periods among epilepsy patients. In this study, we aim to investigate cardiac rhythm abnormalities and HRV during interictal period between drug-naïve patients with idiopathic generalized epilepsy (IGE) and healthy control group. Methods: Twenty-six patients with IGE and 26 healthy individuals included in the study. In order to eliminate any structural cardiac pathology, transthoracic echocardiography was performed in all subjects and time and frequency domain parameters of HRV were evaluated after 24-hour rhythm holter monitoring. Results: Between two groups, no significant difference was detected in terms of mean heart rate and maximum duration between the start of the Q waves and the end of the T waves (QT intervals). In the time domain analysis of HRV, no statically significant difference was detected for standard deviation of all R - R intervals and root-mean-square of successive differences between patient and control group (p = 0,070 and p = 0,104 respectively). In the frequency domain analysis of HRV, patients tended to display lower total power and very low frequency power than did healthy subjects, but the differences were not statistically significant. Conclusions: Our results suggest that there is no major effect of the epilepsy on HRV in patients with IGE. It should be emphasized that, in this study, HRV was evaluated only in patients with IGE and that the results are not proper to be generalized for patients with partial seizures.
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Affiliation(s)
- Ozden Kilinc
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
| | - Altug Cincin
- Department of Cardiology, Marmara University Hospital, Istanbul, Turkey
| | - Aslihan Pehlivan
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
| | - Ipek Midi
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
| | - Alper Kepez
- Department of Cardiology, Marmara University Hospital, Istanbul, Turkey
| | - Kadriye Agan
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
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Ali R. Ictal Cardiac Ryhthym Abnormalities. Open Cardiovasc Med J 2016; 10:105-9. [PMID: 27347227 PMCID: PMC4897004 DOI: 10.2174/1874192401610010105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/20/2015] [Accepted: 10/22/2015] [Indexed: 11/22/2022] Open
Abstract
Cardiac rhythm abnormalities in the context of epilepsy are a well-known phenomenon. However, they are under-recognized and often missed. The pathophysiology of these events is unclear. Bradycardia and asystole are preceded by seizure onset suggesting ictal propagation into the cortex impacting cardiac autonomic function, and the insula and amygdala being possible culprits. Sudden unexpected death in epilepsy (SUDEP) refers to the unanticipated death of a patient with epilepsy not related to status epilepticus, trauma, drowning, or suicide. Frequent refractory generalized tonic-clonic seizures, anti-epileptic polytherapy, and prolonged duration of epilepsy are some of the commonly identified risk factors for SUDEP. However, the most consistent risk factor out of these is an increased frequency of generalized tonic–clonic seizures (GTC). Prevention of SUDEP is extremely important in patients with chronic, generalized epilepsy. Since increased frequency of GTCS is the most consistently reported risk factor for SUDEP, effective seizure control is the most important preventive strategy.
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Affiliation(s)
- Rushna Ali
- Henry Ford Hospital, Department of Neurosurgery, 2799 West Grand Blvd. Detroit, MI 48202, USA
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38
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Meghana A, Sriranjini SJ, Sathyaprabha T, Sanjib S, Prathyusha V, Satishchandra P. Autonomic function in reflex and non-reflex epilepsy--an exploratory study. Acta Neurol Scand 2016; 133:459-65. [PMID: 26369268 DOI: 10.1111/ane.12486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Seizures are known to affect diverse areas of the Central Autonomic Network (CAN) resulting in varied autonomic symptoms. The objectives of the study were to characterize neuro-cardiac autonomic regulation in hot water epilepsy (HWE) with or without spontaneous seizure, and to analyze the effect of Carbamazepine (CBZ). METHODS Seventy patients of HWE [42 drug-naïve 'HWE only' and 28 'HWE with spontaneous complex partial seizure (CPS),' on CBZ] and 40 spontaneous CPS on CBZ were recruited after informed consent. Fifty healthy volunteers served as control. Conventional cardiac autonomic function tests, Heart Rate Variability (HRV), Blood Pressure Variability (BPV), and baroreflex sensitivity (BRS) were performed. RESULTS Significant dysfunction was evidenced in most of the autonomic function parameters in all the epilepsy subgroups when compared with controls. Significant reduction in the parasympathetic activity in HWE patients was observed. Significant impairment of short-term fluctuation of blood pressure in 'HWE with spontaneous CPS' compared to 'healthy volunteers' was detected. Compared to 'HWE only', 'HWE with spontaneous CPS' showed impaired sympathovagal balance. The BRS were also altered in 'HWE with spontaneous CPS' compared to 'HWE only'. The comparison of 'spontaneous CPS' with 'HWE with spontaneous CPS' and 'HWE only' showed reduced parasympathetic and sympathetic activities. CONCLUSION Both cardiovascular reflexes and autonomic cardiovascular regulation were altered in HWE, more so in 'HWE with spontaneous seizures'. Compared to those on CBZ, drug naïve had severe effect on vagal tone and CBZ did not alter cardiac autonomic functions in reflex as well as in non-reflex epilepsies.
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Affiliation(s)
- A. Meghana
- Department of Neurophysiology; National Institute of Mental Health and Neuroscience (NIMHANS); Bangalore India
| | - S. J. Sriranjini
- MS Ramaiah Indic Center for Ayurveda and Integrative Medicine (MSR-ICAIM); Bangalore India
| | - T. Sathyaprabha
- Department of Neurophysiology; National Institute of Mental Health and Neuroscience (NIMHANS); Bangalore India
| | - S. Sanjib
- Department of Neurology; National Institute of Mental Health and Neuroscience (NIMHANS); Bangalore India
| | - V. Prathyusha
- Department of Biostatistics; National Institute of Mental Health and Neuroscience (NIMHANS); Bangalore India
| | - P. Satishchandra
- Department of Neurology; National Institute of Mental Health and Neuroscience (NIMHANS); Bangalore India
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Tomson T, Surges R, Delamont R, Haywood S, Hesdorffer DC. Who to target in sudden unexpected death in epilepsy prevention and how? Risk factors, biomarkers, and intervention study designs. Epilepsia 2016; 57 Suppl 1:4-16. [PMID: 26749012 DOI: 10.1111/epi.13234] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
The risk of dying suddenly and unexpectedly is increased 24- to 28-fold among young people with epilepsy compared to the general population, but the incidence of sudden unexpected death in epilepsy (SUDEP) varies markedly depending on the epilepsy population. This article first reviews risk factors and biomarkers for SUDEP with the overall aim of enabling identification of epilepsy populations with different risk levels as a background for a discussion of possible intervention strategies. The by far most important clinical risk factor is frequency of generalized tonic-clonic seizures (GTCS), but nocturnal seizures, early age at onset, and long duration of epilepsy have been identified as additional risk factors. Lack of antiepileptic drug (AED) treatment or, in the context of clinical trials, adjunctive placebo versus active treatment is associated with increased risks. Despite considerable research, reliable electrophysiologic (electrocardiography [ECG] or electroencephalography [EEG]) biomarkers of SUDEP risk remain to be established. This is an important limitation for prevention strategies and intervention studies. There is a lack of biomarkers for SUDEP, and until validated biomarkers are found, the endpoint of interventions to prevent SUDEP must be SUDEP itself. These interventions, be they pharmacologic, seizure-detection devices, or nocturnal supervision, require large numbers. Possible methods for assessing prevention measures include public health community interventions, self-management, and more traditional (and much more expensive) randomized clinical trials.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Robert Delamont
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Dale C Hesdorffer
- GH Sergievsky Center and Department of Epidemiology, Columbia University, New York, New York, U.S.A
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40
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Dlouhy BJ, Gehlbach BK, Richerson GB. Sudden unexpected death in epilepsy: basic mechanisms and clinical implications for prevention. J Neurol Neurosurg Psychiatry 2016; 87:402-13. [PMID: 26979537 DOI: 10.1136/jnnp-2013-307442] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 05/13/2015] [Indexed: 12/14/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death in patients with intractable epilepsy. The substantial lifetime risk of SUDEP and the lack of a clear pathophysiological connection between epilepsy itself and sudden death have fuelled increased attention to this phenomenon. Understanding the mechanisms underlying SUDEP is paramount to developing preventative strategies. In this review, we discuss SUDEP population studies, case-control studies, witnessed and monitored cases, as well as human seizure cardiorespiratory findings related to SUDEP, and SUDEP animal models. We integrate these data to suggest the most probable mechanisms underlying SUDEP. Understanding the modifiable risk factors and pathophysiology allows us to discuss potential preventative strategies.
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Affiliation(s)
- Brian J Dlouhy
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - George B Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa, USA Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, Iowa, USA
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Cerebral Hemispheric Lateralization Associated with Hippocampal Sclerosis May Affect Interictal Cardiovascular Autonomic Functions in Temporal Lobe Epilepsy. EPILEPSY RESEARCH AND TREATMENT 2016; 2016:7417540. [PMID: 27006827 PMCID: PMC4783555 DOI: 10.1155/2016/7417540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 01/11/2016] [Accepted: 01/26/2016] [Indexed: 11/18/2022]
Abstract
It is well established that the temporal lobe epilepsy (TLE) is linked to the autonomic nervous system dysfunctions. Seizures alter the function of different systems such as the respiratory, cardiovascular, gastrointestinal, and urogenital systems. The aim of this work was to evaluate the possible factors which may be involved in interictal cardiovascular autonomic function in temporal lobe epilepsy with complex partial seizures, and with particular attention to hippocampal sclerosis. The study was conducted in 30 patients with intractable temporal lobe epilepsy (19 with left hippocampal sclerosis, 11 with right hippocampal sclerosis). All subjects underwent four tests of cardiac autonomic function: heart rate changes in response to deep breathing, heart rate, and blood pressure variations throughout resting activity and during hand grip, mental stress, and orthostatic tests. Our results show that the right cerebral hemisphere predominantly modulates sympathetic activity, while the left cerebral hemisphere mainly modulates parasympathetic activity, which mediated tachycardia and excessive bradycardia counterregulation, both of which might be involved as a mechanism of sudden unexpected death in epilepsy patients (SUDEP).
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42
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Abstract
Sudden unexpected death in epilepsy is likely caused by a cascade of events affecting the vegetative nervous system leading to cardiorespiratory failure and death. Multiple genetic, electrophysiological, neurochemical, and pharmacological cardiac alterations have been associated with epilepsy, which can affect autonomic regulation of the heart and predispose patients to sudden unexpected death in epilepsy. These cardiac and autonomic changes are more frequently seen in patients with longstanding and medication refractory epilepsy and may be a prerequisite for sudden unexpected death in epilepsy. Cardiac changes are also observed within the immediate periictal period in patients with and without preexisting cardiac pathology and could be the tipping point in the cascade of events compromising autonomic, respiratory, and cardiac function during an epileptic convulsion. Better understanding if and how these cardiac alterations can make a particular individual with epilepsy more susceptible to sudden unexpected death in epilepsy will hopefully lead us to more effective preventative strategies.
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43
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Evaluation of Cardiovascular Risk Factors in the Wistar Audiogenic Rat (WAR) Strain. PLoS One 2015; 10:e0129574. [PMID: 26029918 PMCID: PMC4450865 DOI: 10.1371/journal.pone.0129574] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 05/11/2015] [Indexed: 11/24/2022] Open
Abstract
Introduction Risk factors for life-threatening cardiovascular events were evaluated in an experimental model of epilepsy, the Wistar Audiogenic Rat (WAR) strain. Methods We used long-term ECG recordings in conscious, one year old, WAR and Wistar control counterparts to evaluate spontaneous arrhythmias and heart rate variability, a tool to assess autonomic cardiac control. Ventricular function was also evaluated using the pressure-volume conductance system in anesthetized rats. Results Basal RR interval (RRi) was similar between WAR and Wistar rats (188±5 vs 199±6 ms). RRi variability strongly suggests that WAR present an autonomic imbalance with sympathetic overactivity, which is an isolated risk factor for cardiovascular events. Anesthetized WAR showed lower arterial pressure (92±3 vs 115±5 mmHg) and exhibited indices of systolic dysfunction, such as higher ventricle end-diastolic pressure (9.2±0.6 vs 5.6±1 mmHg) and volume (137±9 vs 68±9 μL) as well as lower rate of increase in ventricular pressure (5266±602 vs 7320±538 mmHg.s-1). Indices of diastolic cardiac function, such as lower rate of decrease in ventricular pressure (-5014±780 vs -7766±998 mmHg.s-1) and a higher slope of the linear relationship between end-diastolic pressure and volume (0.078±0.011 vs 0.036±0.011 mmHg.μL), were also found in WAR as compared to Wistar control rats. Moreover, Wistar rats had 3 to 6 ventricular ectopic beats, whereas WAR showed 15 to 30 ectopic beats out of the 20,000 beats analyzed in each rat. Conclusions The autonomic imbalance observed previously at younger age is also present in aged WAR and, additionally, a cardiac dysfunction was also observed in the rats. These findings make this experimental model of epilepsy a valuable tool to study risk factors for cardiovascular events in epilepsy.
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Stavrinou ML, Sakellaropoulos GC, Trachani E, Sirrou V, Polychronopoulos P, Nikiforidis G, Chroni E. Methodological issues in the spectral analysis of the heart rate variability: Application in patients with epilepsy. Biomed Signal Process Control 2014. [DOI: 10.1016/j.bspc.2014.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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45
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Finsterer J, Wahbi K. CNS-disease affecting the heart: brain-heart disorders. J Neurol Sci 2014; 345:8-14. [PMID: 25034054 DOI: 10.1016/j.jns.2014.07.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/27/2014] [Accepted: 07/01/2014] [Indexed: 01/09/2023]
Abstract
There are a number of hereditary and non-hereditary central nervous system (CNS) disorders, which directly or indirectly affect the heart (brain-heart disorders). The most well-known of these CNS-disorders are epilepsy, stroke, subarachanoid bleeding, bacterial meningitis, and head injury. In addition, a number of hereditary and non-hereditary neurodegenerative disorders may impair cardiac functions. Affection of the heart may manifest as arrhythmias, cardiomyopathy, or autonomic dysfunction. Rarer cardiac complications of CNS disorders include heart failure, systolic or diastolic dysfunction, myocardial infarction, arterial hypertension, or pulmonary hypertension. Cardiomyopathy induced by hereditary CNS disease mainly include stress-induced myocardial dysfunction, known as Takotsubo syndrome (TTS). CNS disease triggering TTS includes epilepsy, ischemic stroke, subarachnoid bleeding, or PRES syndrome. Arrhythmias induced by hereditary CNS disease include supraventricular or ventricular arrhythmias leading to palpitations, dizziness, vertigo, fainting, syncope, (near) sudden cardiac death, or sudden unexplained death in epilepsy (SUDEP). Appropriate management of cardiac involvement in CNS-disorders is essential to improve outcome of affected patients.
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Affiliation(s)
| | - Karim Wahbi
- Paris-Descartes, Sorbonne Paris Cite University, 75006 Paris, France; AP-HP, Cardiology Department, Cochin Hospital, Paris, France; AP-HP, Pitié-Salpêtrière Hospital, Neurology Department, Paris, France
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46
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Can heart rate variability in children with epilepsy be used to predict seizures? Seizure 2014; 23:357-62. [DOI: 10.1016/j.seizure.2014.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 11/22/2022] Open
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Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy, with an estimated 35% lifetime risk in this patient population. There is a surprising lack of awareness among patients and physicians of this increased risk of sudden death: in a recent survey, only 33% of Canadian paediatricians who treated patients with epilepsy knew the term SUDEP. Controversy prevails over whether cardiac arrhythmia or respiratory arrest is more important as the primary cause of death. Effective preventive strategies in high-risk patients will rely on definition of the mechanisms that lead from seizures to death. Here, we summarize evidence for the mechanisms that cause cardiac, respiratory and arousal abnormalities during the ictal and postictal period. We highlight potential cellular mechanisms underlying these abnormalities, such as a defect in the serotonergic system, ictal adenosine release, and changes in autonomic output. We discuss genetic mutations that cause Dravet and long QT syndromes, both of which are linked with increased risk of sudden death. We then highlight possible preventive interventions that are likely to decrease SUDEP incidence, including respiratory monitoring in epilepsy monitoring units and overnight supervision. Finally, we discuss treatments, such as selective serotonin reuptake inhibitors, that might be personalized to a specific genetic or pathological defect.
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48
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Behbahani S, Jafarnia Dabanloo N, Motie Nasrabadi A, Teixeira CA, Dourado A. A new algorithm for detection of epileptic seizures based on HRV signal. J EXP THEOR ARTIF IN 2014. [DOI: 10.1080/0952813x.2013.861874] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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49
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Malik GA, Smith PEM. Increasing awareness of sudden unexpected death in epilepsy. Expert Rev Neurother 2014; 13:1371-82. [DOI: 10.1586/14737175.2013.861741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Dericioglu N, Demirci M, Cataltepe O, Akalan N, Saygi S. Heart rate variability remains reduced and sympathetic tone elevated after temporal lobe epilepsy surgery. Seizure 2013; 22:713-8. [DOI: 10.1016/j.seizure.2013.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/29/2022] Open
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