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Yan SP, Song X, Wei L, Gong YS, Hu HY, Li YQ. Performance of heart rate adjusted heart rate variability for risk stratification of sudden cardiac death. BMC Cardiovasc Disord 2023; 23:144. [PMID: 36949420 PMCID: PMC10032001 DOI: 10.1186/s12872-023-03184-0] [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: 12/02/2022] [Accepted: 03/14/2023] [Indexed: 03/24/2023] Open
Abstract
PURPOSE As a non-invasive tool for the assessment of cardiovascular autonomic function, the predictive value of heart rate variability (HRV) for sudden cardiac death (SCD) risk stratification remains unclear. In this study, we investigated the performance of the individualized heart rate (HR) adjusted HRV (HRVI) for SCD risk stratification in subjects with diverse risks. METHODS A total of 11 commonly used HRV metrics were analyzed in 192 subjects, including 88 healthy controls (low risk group), 82 hypertrophic cardiomyopathy (HCM) patients (medium risk group), and 22 SCD victims (high risk group). The relationship between HRV metrics and HR was examined with long-term and short-term analysis. The performance HRVI was evaluated by area under the receiver operating characteristic curve (AUC) and covariance of variation (CV). RESULTS Most of the HRV metrics were exponentially decayed with the increase of HR, while the exponential power coefficients were significantly different among groups. The HRVI metrics discriminated low, medium and high risk subjects with a median AUC of 0.72[0.11], which was considerably higher than that of the traditional long-term (0.63[0.04]) and short-term (0.58[0.05]) HRV without adjustment. The average CV of the HRVI metrics was also significantly lower than traditional short-term HRV metrics (0.09 ± 0.02 vs. 0.24 ± 0.13, p < 0.01). CONCLUSIONS Subjects with diverse risks of SCD had similar exponential decay relationship between HRV metrics and HR, but with different decaying rates. HRVI provides reliable and robust estimation for risk stratification of SCD.
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Affiliation(s)
- Su-Peng Yan
- Department of Biomedical Engineering and Imaging Medicine, Army Medical University, 30 Gaotanyan Main Street, Chongqing, 400038, China
| | - Xin Song
- Department of Biomedical Engineering and Imaging Medicine, Army Medical University, 30 Gaotanyan Main Street, Chongqing, 400038, China
| | - Liang Wei
- Department of Biomedical Engineering and Imaging Medicine, Army Medical University, 30 Gaotanyan Main Street, Chongqing, 400038, China
| | - Yu-Shun Gong
- Department of Biomedical Engineering and Imaging Medicine, Army Medical University, 30 Gaotanyan Main Street, Chongqing, 400038, China
| | - Hou-Yuan Hu
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, 400038, China
| | - Yong-Qin Li
- Department of Biomedical Engineering and Imaging Medicine, Army Medical University, 30 Gaotanyan Main Street, Chongqing, 400038, China.
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How predictable is heart rate variability in Brazilian patients with drug-resistant mesial temporal lobe epilepsy? Epilepsy Behav 2022; 128:108532. [PMID: 35101842 DOI: 10.1016/j.yebeh.2021.108532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/23/2021] [Accepted: 12/25/2021] [Indexed: 11/22/2022]
Abstract
This study aimed to compare heart rate variability (HRV) in patients with drug-resistant mesial temporal lobe epilepsy (MTLE) with healthy controls and to analyze their clinical and sociodemographic variables predictive for HRV. Thirty-nine consecutive patients with drug-resistant MTLE were included in the study. The control group included twenty-seven healthy participants matched by age and gender. Seven HRV indices (HR, RR, rMSSD, SDNN, LF, HF, and LF/HF) were compared between patients and controls. The clinical and sociodemographic variables independently associated with the HRV indices were identified by multiple linear regression. In comparison with controls, the patients with MTLE showed a significant reduction in RR, rMSSD, SDNN, LF, HF, and LF/HF indices (t value 1.97-5.97, p < 0.05). Multiple regression models showed that disease duration predicted 11-22% of the analyzed HRV indices. Time domain indices showed higher association with disease duration than coefficients in frequency domain. Patients with drug-resistant MTLE present cardiac autonomic tone dysfunction, showing a significant reduction in their HRV indices (RR, SDNN, rMSSD, LF, HF, and LF/HF). Disease duration has a negative association with all HRV indices. This study contributes to understanding the relationship between MTLE and the cardiac autonomic tone, with possible implications for sudden unexpected death in epilepsy.
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Karoly PJ, Stirling RE, Freestone DR, Nurse ES, Maturana MI, Halliday AJ, Neal A, Gregg NM, Brinkmann BH, Richardson MP, La Gerche A, Grayden DB, D'Souza W, Cook MJ. Multiday cycles of heart rate are associated with seizure likelihood: An observational cohort study. EBioMedicine 2021; 72:103619. [PMID: 34649079 PMCID: PMC8517288 DOI: 10.1016/j.ebiom.2021.103619] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/23/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022] Open
Abstract
Background Circadian and multiday rhythms are found across many biological systems, including cardiology, endocrinology, neurology, and immunology. In people with epilepsy, epileptic brain activity and seizure occurrence have been found to follow circadian, weekly, and monthly rhythms. Understanding the relationship between these cycles of brain excitability and other physiological systems can provide new insight into the causes of multiday cycles. The brain-heart link has previously been considered in epilepsy research, with potential implications for seizure forecasting, therapy, and mortality (i.e., sudden unexpected death in epilepsy). Methods We report the results from a non-interventional, observational cohort study, Tracking Seizure Cycles. This study sought to examine multiday cycles of heart rate and seizures in adults with diagnosed uncontrolled epilepsy (N=31) and healthy adult controls (N=15) using wearable smartwatches and mobile seizure diaries over at least four months (M=12.0, SD=5.9; control M=10.6, SD=6.4). Cycles in heart rate were detected using a continuous wavelet transform. Relationships between heart rate cycles and seizure occurrence were measured from the distributions of seizure likelihood with respect to underlying cycle phase. Findings Heart rate cycles were found in all 46 participants (people with epilepsy and healthy controls), with circadian (N=46), about-weekly (N=25) and about-monthly (N=13) rhythms being the most prevalent. Of the participants with epilepsy, 19 people had at least 20 reported seizures, and 10 of these had seizures significantly phase locked to their multiday heart rate cycles. Interpretation Heart rate cycles showed similarities to multiday epileptic rhythms and may be comodulated with seizure likelihood. The relationship between heart rate and seizures is relevant for epilepsy therapy, including seizure forecasting, and may also have implications for cardiovascular disease. More broadly, understanding the link between multiday cycles in the heart and brain can shed new light on endogenous physiological rhythms in humans. Funding This research received funding from the Australian Government National Health and Medical Research Council (investigator grant 1178220), the Australian Government BioMedTech Horizons program, and the Epilepsy Foundation of America's ‘My Seizure Gauge’ grant.
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Affiliation(s)
- Philippa J Karoly
- Graeme Clark Institute for Biomedical Engineering, The University of Melbourne, Australia; Seer Medical, Australia.
| | - Rachel E Stirling
- Department of Biomedical Engineering, The University of Melbourne, Australia
| | | | - Ewan S Nurse
- Seer Medical, Australia; Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Matias I Maturana
- Seer Medical, Australia; Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Amy J Halliday
- Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Andrew Neal
- Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Nicholas M Gregg
- Bioelectronics Neurophysiology and Engineering Lab, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Benjamin H Brinkmann
- Bioelectronics Neurophysiology and Engineering Lab, Department of Neurology, Mayo Clinic, Rochester, MN
| | | | - Andre La Gerche
- Sports Cardiology Laboratory, Baker Heart & Diabetes Institute, Melbourne, Australia
| | - David B Grayden
- Department of Biomedical Engineering, The University of Melbourne, Australia
| | - Wendyl D'Souza
- Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Mark J Cook
- Graeme Clark Institute for Biomedical Engineering, The University of Melbourne, Australia; Departments of Medicine and Neurology, The University of Melbourne, St Vincent's Hospital, Melbourne, Australia
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Melo HM, Brum Marques JL, Fialho GL, Wolf P, D'Ávila A, Lin K, Walz R. Ultra-short heart rate variability reliability for cardiac autonomic tone assessment in mesial temporal lobe epilepsy. Epilepsy Res 2021; 174:106662. [PMID: 34023634 DOI: 10.1016/j.eplepsyres.2021.106662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 01/15/2023]
Abstract
Autonomic dysfunction in epilepsy is well-described. Heart rate variability (HRV) is a useful method to evaluate autonomic cardiac tone. Cardiac dysfunction may be involved in sudden unexpected death in epilepsy (SUDEP). HRV is a promising biomarker to enlighten the heart-brain axis role in SUDEP, but the required duration for a proper HRV recording in clinical routine remains unknown. This study aimed to verify the reliability of ultra-short HRV indices to evaluate cardiac autonomic tone in patients with epilepsy (PWE). Thirty-nine patients with mesial temporal lobe epilepsy (MTLE) had electrocardiogram recordings during the first day of video-EEG. Pearson's correlations were performed to evaluate the association between ultra-short HRV indices (five 1-min and five 30-s epochs) with standard time recording (5-min) and ANOVA compared the differences between mean HRV indices across epochs. Time domain (TD) indices showed higher mean r values when compared to frequency domain (FD) indices in 1-min (TD: r 0.80-0.99, FD: r 0.61-0.95) and 30-s epochs (TD: r 0.69-0.99, only high frequency: mean r values of 0.96). ANOVA evidenced that standard deviation of RR intervals and very low frequency means had at least 3 epochs significantly different for 1-min and 30-s epochs. Root mean square of the successive differences of RR intervals (rMSSD) presented higher Pearson's coefficient values and lower percentage of variation at 1-min or 30-s epochs in comparison to other HRV indices. In conclusion, rMSSD is the most reliable ultra-short HRV index for cardiac autonomic tone assessment in MTLE. The prognostic value of ultra-short HRV for cardiovascular risk evaluation in epilepsy remains to be determined in future studies.
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Affiliation(s)
- Hiago Murilo Melo
- Center for Applied Neuroscience, University Hospital (HU), UFSC, Florianópolis, SC, Brazil; Graduate Program in Neuroscience, UFSC, Florianópolis, SC, Brazil
| | | | - Guilherme Loureiro Fialho
- Center for Applied Neuroscience, University Hospital (HU), UFSC, Florianópolis, SC, Brazil; Cardiology Service, Department of Internal Medicine, HU, UFSC, Florianópolis, SC, Brazil
| | - Peter Wolf
- Neurology Division, Department of Internal Medicine, University Hospital, UFSC, Florianópolis, SC, Brazil; Danish Epilepsy Centre, Dianalund, Denmark; Graduate Program in Medical Sciences, UFSC, Florianópolis, Brazil
| | | | - Katia Lin
- Center for Applied Neuroscience, University Hospital (HU), UFSC, Florianópolis, SC, Brazil; Neurology Division, Department of Internal Medicine, University Hospital, UFSC, Florianópolis, SC, Brazil; Graduate Program in Medical Sciences, UFSC, Florianópolis, Brazil; Center for Epilepsy Surgery of Santa Catarina (CEPESC), HU, UFSC, Florianópolis, SC, Brazil
| | - Roger Walz
- Center for Applied Neuroscience, University Hospital (HU), UFSC, Florianópolis, SC, Brazil; Graduate Program in Neuroscience, UFSC, Florianópolis, SC, Brazil; Neurology Division, Department of Internal Medicine, University Hospital, UFSC, Florianópolis, SC, Brazil; Graduate Program in Medical Sciences, UFSC, Florianópolis, Brazil; Center for Epilepsy Surgery of Santa Catarina (CEPESC), HU, UFSC, Florianópolis, SC, Brazil.
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Vieluf S, El Atrache R, Hammond S, Touserkani FM, Loddenkemper T, Reinsberger C. Peripheral multimodal monitoring of ANS changes related to epilepsy. Epilepsy Behav 2019; 96:69-79. [PMID: 31100658 DOI: 10.1016/j.yebeh.2019.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 11/19/2022]
Abstract
The goal of this study was to evaluate and summarize the current literature on multimodal changes of the autonomic nervous system (ANS) in people with epilepsy (PWE). We included studies reporting ANS measures of at least two modalities and with a minimum of one group of people with epilepsy. We screened two hundred eighty-three abstracts and sixty-six full texts, of which twenty-two met our inclusion criteria. Eleven studies reported ictal and interictal cardiac and respiratory changes. Three studies investigated the correlation between cardiac and respiratory markers, whereby two found no correlation and one showed a relation. Six studies evaluated electrodermal and cardiac parameters and showed effects on both ANS subsystems that jointly indicate a shift toward increased sympathetic activity for people with epilepsy during rest and during activity. Two studies assessed three modalities and reveal epilepsy-related alterations within the ANS. In summary, there is a growing interest in multimodal monitoring approaches, such as combining at least two ANS modalities, to describe epilepsy-related changes in ANS activity and to test for the potential to use ANS markers for seizure detection and prediction. Most studies report multiple unimodal analyses while only few studies analyzed multimodal patterns. Patterns of changes depend on the type of epilepsy and differ on an individual level; therefore, a multimodal approach might offer an approach to more individualized monitoring and, ultimately, management.
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Affiliation(s)
- Solveig Vieluf
- Institute of Sports Medicine, Department Sports & Health, Paderborn University, Paderborn, Germany; Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Rima El Atrache
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Sarah Hammond
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Fatemeh Mohammadpour Touserkani
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA; Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Tobias Loddenkemper
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Claus Reinsberger
- Institute of Sports Medicine, Department Sports & Health, Paderborn University, Paderborn, Germany; Edward B. Bromfield Epilepsy Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Step on the Gas! Focal Seizures with Autonomic Features. Can J Neurol Sci 2019; 46:360-362. [DOI: 10.1017/cjn.2019.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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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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Quatman-Yates C, Bailes A, Constand S, Sroka MC, Nissen K, Kurowski B, Hugentobler J. Exertional Tolerance Assessments After Mild Traumatic Brain Injury: A Systematic Review. Arch Phys Med Rehabil 2018; 99:994-1010. [PMID: 29277373 PMCID: PMC5924441 DOI: 10.1016/j.apmr.2017.11.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/09/2017] [Accepted: 11/25/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To review the literature to identify and summarize strategies for evaluating responses to physical exertion after mild traumatic brain injury (mTBI) for clinical and research purposes. DATA SOURCES PubMed and EBSCOhost through December 31, 2016. STUDY SELECTION Two independent reviewers selected studies based on the following criteria: (1) inclusion of participants with mTBI/concussion, (2) use of a measurement of physiological or psychosomatic response to exertion, (3) a repeatable description of the exertion protocol was provided, (4) a sample of at least 10 participants with a mean age between 8 and 65 years, and (5) the article was in English. The search process yielded 2685 articles, of which 14 studies met the eligibility requirements. DATA EXTRACTION A quality assessment using a checklist was conducted for each study by 2 independent study team members and verified by a third team member. Data were extracted by one team member and verified by a second team member. DATA SYNTHESIS A qualitative synthesis of the studies revealed that most protocols used a treadmill or cycle ergometer as the exercise modality. Protocol methods varied across studies including differences in initial intensity determination, progression parameters, and exertion duration. Common outcome measures were self-reported symptoms, heart rate, and blood pressure. CONCLUSIONS The strongest evidence indicates that exertional assessments can provide important insight about mTBI recovery and should be administered using symptoms as a guide. Additional studies are needed to verify optimal modes and protocols for post-mTBI exertional assessments.
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Affiliation(s)
- Catherine Quatman-Yates
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH.
| | - Anna Bailes
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Sara Constand
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Mary Claire Sroka
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH; Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Katharine Nissen
- Research in Patient Services, Cincinnati Children's Hospital, Cincinnati, OH
| | - Brad Kurowski
- Physical Medicine and Rehabilitation, Cincinnati Children's Hospital, Cincinnati, OH
| | - Jason Hugentobler
- Division of Occupational and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, OH
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Vorkapić M, Useinović N, Janković M, Hrnčić D. Heart rate variability processing in epilepsy: The role in detection and prediction of seizures and SUDEP. MEDICINSKI PODMLADAK 2018. [DOI: 10.5937/mp69-18553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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10
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Desai R, Rupareliya C, Patel U, Naqvi S, Patel S, Lunagariya A, Mahuwala Z. Burden of Arrhythmias in Epilepsy Patients: A Nationwide Inpatient Analysis of 1.4 Million Hospitalizations in the United States. Cureus 2017; 9:e1550. [PMID: 29018647 PMCID: PMC5630461 DOI: 10.7759/cureus.1550] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Arrhythmias have been one of the common complications in epilepsy patients and have also been the reason for death. However, limited data exist about the burden and outcomes of arrhythmias by subtypes in epilepsy. Our study aims at evaluating the burden and differences in outcomes of various subtypes of arrhythmias in epilepsy patient population. The Nationwide Inpatient Sample (NIS) database from 2014 was examined for epilepsy and arrhythmias related discharges using appropriate International Classification of Disease, Ninth Revision Clinical Modification (ICD-9-CM) codes. The frequency of arrhythmias, gender differences in arrhythmia by subtypes, in-hospital outcomes and mortality predictors was analyzed. A total of 1,424,320 weighted epilepsy patients was determined and included in this study. Around 23.9% (n =277,230) patients had cardiac arrhythmias. The most frequent arrhythmias in the descending frequency were: atrial fibrillation (AFib) 9.7%, other unspecified causes 7.3%, sudden cardiac arrest (SCA) 1.4%, bundle branch block (BBB) 1.2%, ventricular tachycardia (VT) 1%. Males were more predisposed to cardiac arrhythmias compared to females (OR [odds ratio]: 1.1, p <0.001). The prevalence of most subtypes arrhythmias was higher in males. Arrhythmias were present in nearly a quarter of patients with epilepsy. Life threatening arrhythmias were more common in male patients. The length of stay (LOS) and mortality were significantly higher in epilepsy patients with arrhythmia. It is imperative to develop early diagnosis and prompt therapeutic measures to reduce this burden and poor outcomes due to concomitant arrhythmias in epilepsy patients.
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Affiliation(s)
- Rupak Desai
- Research Coordinator, Atlanta Veterans Affairs Medical Center
| | | | | | - Syeda Naqvi
- Jinnah Postgraduate Medical Centre, Jinnah Sindh Medical University (SMC)
| | - Smit Patel
- Department of Neurology, University of Connecticut Health Center
| | | | - Zabeen Mahuwala
- Department of Neurology, University Of Kentucky College of Medicine
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Trivisano M, Bellusci M, Terracciano A, De Palma L, Pietrafusa N, Valeriani M, Vigevano F, Specchio. TBC1D24 gene mutations are associated with high risk of sudden unexpected death. Epilepsy Behav 2017; 72:208-209. [PMID: 28606688 DOI: 10.1016/j.yebeh.2017.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Affiliation(s)
- M Trivisano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - M Bellusci
- Pediatric Neurology, "12th of October" University Hospital, Avenida de Córdoba s/n, 28041 Madrid, Spain
| | - A Terracciano
- Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, Viale Di San Paolo, 15, 00146 Rome, Italy
| | - L De Palma
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - N Pietrafusa
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - M Valeriani
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - F Vigevano
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy
| | - Specchio
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRRCS, Piazza Sant'Onofrio 4, 00165 Rome, Italy.
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