Neuropathology of epilepsy: epilepsy-related deaths and SUDEP

Seizure-related deaths in children: The expanding spectrum

Although seizures are common in children, they are often overlooked as a potential cause of death. Febrile and nonfebrile seizures can be fatal in children with or without an epilepsy diagnosis and may go unrecognized by parents or physicians. Sudden unexpected infant deaths, sudden unexplained death in childhood, and sudden unexpected death in epilepsy share clinical, neuropathological, and genetic features, including male predominance, unwitnessed deaths, death during sleep, discovery in the prone position, hippocampal abnormalities, and variants in genes regulating cardiac and neuronal excitability. Additionally, epidemiological studies reveal that miscarriages are more common among individuals with a personal or family history of epilepsy, suggesting that some fetal losses may result from epileptic factors. The spectrum of seizure-related deaths in pediatrics is wide and underappreciated; accurately estimating this mortality and understanding its mechanism in children is critical to developing effective education and interventions to prevent these tragedies.

Corrected QT interval and QT dispersion in temporal lobe epilepsy

Background

Cardiac arrhythmias are expected among patients with epilepsy due to the effect of anti-epileptic drugs. Temporal lobe epilepsy also causes autonomic seizures that may affect heart rhythm. Prolongation of the corrected QT interval and QT dispersion is a risk factor for cardiac arrhythmia.

Objectives

We aimed to assess corrected QT interval and QT dispersion in patients with epilepsy and if there is a difference between patients with temporal epilepsy versus non-temporal epilepsy.

Methods

This study was conducted on 100 patients (50 patients with temporal epilepsy and 50 patients with non-temporal epilepsy) and 50 age- and sex-matched healthy controls. They underwent a prolonged (6 to 24 h) 22 channel computerized electroencephalogram monitor with a 10–20 system. QT dispersion, QT interval, and corrected QT interval (using Bazett’s formula) were calculated.

Results

This study showed significantly higher QT dispersion and corrected QT interval in patients with epilepsy when compared to the age- and sex-matched control group (P < 0.001, P < 0.001). Also, the corrected QT interval and QT dispersion were significantly higher in temporal epilepsy patients when compared to the non-temporal group (P < 0.001, P < 0.001).

Conclusion

Corrected QT interval and QT dispersion are higher in epileptic patients and more among temporal epilepsy patients in comparison to non-temporal epilepsy patients.

Sudden death in epilepsy: There is room for intracranial pressure

INTRODUCTION

Sudden unexpected death in patients with epilepsy (SUDEP) remains a poorly understood entity, and it is unclear whether the same pathomechanisms underlie all sudden deaths occurring in patients with epilepsy. One aspect not included in current models of SUDEP is the role of increased intracranial pressure (ICP) which can be observed immediately upon seizure activity in neurosurgical practice.

METHODS

We conducted a systematic review of the occurrence of edema in patients with epilepsy reported to have died of sudden death who underwent brain autopsy or postmortem brain imaging and discuss how increased ICP may contribute to clinical features of SUDEP.

RESULTS

19 eligible studies comprising a total of 623 patients were identified. Edema-mostly mild or moderate-was reported in 17% of cases and 74% of studies. 1% (n = 6) of the overall cases were clearly identified as having Dravet syndrome or an SCN1A mutation. In these patients, edema was found in 4 (67%) of cases.

CONCLUSION

Edema is regularly found in patients with epilepsy classified to have died from SUDEP. We argue that seizures preceding SUDEP may in certain cases elicit acute edema which may represent an additional contributing factor in the cascade of events leading to sudden death of patients with epilepsy. Furthermore, we hypothesize that mild edema may especially progress to severe edema in patients with sodium channel mutations which may represent an important mechanism to investigate in the context of understanding the significantly elevated risk of SUDEP in patients with SCN1A mutations.

Hippocampal abnormalities and seizures: a 16-year single center review of sudden unexpected death in childhood, sudden unexpected death in epilepsy and SIDS

Sudden Unexpected Death in Childhood (SUDC) is the unexplained death of children aged between 1 and 18 years old. Hippocampal abnormalities have previously been described in Sudden Unexpected Death in Epilepsy (SUDEP) and it is possible that SUDC shares similar pathogenic mechanisms with SUDEP. Our aim was to determine the prevalence of hippocampal abnormalities, history of seizures and demographic features in our caseload of SUDC, SUDEP and SIDS cases. A review of post-mortem reports from 2003 to 2018 was carried out to identify cases of SUDC, SUDEP and SIDS. Histological evidence of hippocampal abnormalities, patient demographics (age, gender), sleeping position, and past medical history (history of seizures and illness 72 hours prior to death) were recorded. Statistical analysis was performed to compare the three groups. 48 SUDC, 18 SUDEP and 358 SIDS cases were identified. Hippocampal abnormalities associated with temporal lobe epilepsy were found in 44.4% of SUDC cases. 5/15 SUDC cases with a history of seizures demonstrated hippocampal abnormalities. SUDC cases were also more likely to be found prone compared to SIDS cases. In comparison with SIDS, both SUDC and SUDEP cases were more likely to demonstrate hippocampal abnormalities (SUDC: (OR = 9.4, 95% CI: 3.1-29.1, p < 0.001; SUDEP: OR = 35.4, 95% CI: 8.3-151.5, p < 0.001). We found a potential link between hippocampal abnormalities and epileptic seizures in SUDC. A concerted effort should be directed towards consistent sampling and standardized description of the hippocampus and clinical correlation with a history of seizures/epilepsy in postmortem reports.

Review on post-mortem diagnosis in suspected SUDEP: Currently still a difficult task for Forensic Pathologists

Sudden and unexpected death in epilepsy (SUDEP) represents the predominant cause of premature deaths in young adults with epilepsy and is more common with patients with poorly controlled and generalized convulsive seizures. It is reported that there are 1,16 cases for every 1000 subjects affected with epilepsy. This review takes stock of the current problems and issues in the autopsy of cases of sudden death with epileptic people. For this purpose, all the possible findings of post-mortem examinations reported in the literature were analyzed and summarized, which can currently be considered useful for autopsy diagnoses as well as in the comprehension of the physiopathology of SUDEP. The enormous limitation of forensic pathology studies is the complete lack of a specific SUDEP diagnostic marker. Only in a few cases was it possible to find pathological signs of the brain that would clarify epilepsy-related deaths. Genetic research has tracked down variants of neurocardiac genes of ion channels in a restricted percentage of suspected SUDEP cases. The actual pathogenicity test requires an in-depth statistical analysis in order to prove there is a real excess of variants and evidence that the mutation alters the function. Despite scientific efforts, it is often difficult to distinguish SUDEP from other causes of sudden death. For these reasons, it will be necessary to create an international standard SUDEP death scene investigation and postmortem examination protocols. Further future studies of immunohistochemistry or genetics may help and may facilitate post-mortem diagnosis in cases of presumed SUDEP.

Antiepileptic Effects of Protein-Rich Extract from Bombyx batryticatus on Mice and Its Protective Effects against H2O2-Induced Oxidative Damage in PC12 Cells via Regulating PI3K/Akt Signaling Pathways

Bombyx batryticatus is a known traditional Chinese medicine (TCM) utilized to treat convulsions, epilepsy, cough, asthma, headaches, and purpura in China for thousands of years. This study is aimed at investigating the antiepileptic effects of protein-rich extracts from Bombyx batryticatus (BBPs) on seizure in mice and exploring the protective effects of BBPs against H₂O₂-induced oxidative stress in PC12 cells and their underlying mechanisms. Maximal electroshock-induced seizure (MES) and pentylenetetrazole- (PTZ-) induced seizure in mice and the histological analysis were carried out to evaluate the antiepileptic effects of BBPs. The cell viability of PC12 cells stimulated by H₂O₂ was determined by MTT assay. The apoptosis and ROS levels of H₂O₂-stimulated PC12 cells were determined by flow cytometry analysis. Furthermore, the levels of malondialdehyde (MDA), superoxide dismutase (SOD), lactate dehydrogenase (LDH), and glutathione (GSH) in PC12 cells were assayed by ELISA and expressions of caspase-3, caspase-9, Bax, Bcl-2, PI3K, Akt, and p-Akt were evaluated by Western blotting and quantitative real-time polymerase chain reaction (RT-qPCR) assays. The results revealed that BBPs exerted significant antiepileptic effects on mice. In addition, BBPs increased the cell viability of H₂O₂-stimulated PC12 cells and reduced apoptotic cells and ROS levels in H₂O₂-stimulated PC12 cells. By BBPs treatments, the levels of MDA and LDH were reduced and the levels of SOD and GSH-Px were increased in H₂O₂-stimulated PC12 cells. Moreover, BBPs upregulated the expressions of PI3K, Akt, p-Akt, and Bcl-2, whereas they downregulated the expressions of caspase-9, caspase-3, and Bax in H₂O₂-stimulated PC12 cells. These findings suggested that BBPs possessed potential antiepileptic effects on MES and PTZ-induced seizure in mice and protective effects on H₂O₂-induced oxidative stress in PC12 cells by exerting antioxidative and antiapoptotic effects via PI3K/Akt signaling pathways.