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Aurlien DB, Taubøll E. Antiseizure medication and SUDEP - a need for unifying methodology in research. Front Neurol 2024; 15:1385468. [PMID: 38694773 PMCID: PMC11061368 DOI: 10.3389/fneur.2024.1385468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/03/2024] [Indexed: 05/04/2024] Open
Abstract
The risk of sudden unexpected death in epilepsy (SUDEP) increases with the frequency of generalized tonic-clonic seizures. Carbamazepine (CBZ) and lamotrigine (LTG) have been suggested to increase the risk. However, the prevailing viewpoint is that the choice of antiseizure medication (ASM) does not influence the occurrence. We have explored the approach to addressing this question in relevant studies to evaluate the validity of the conclusions reached. A systematic search was performed in PubMed to identify all controlled studies on SUDEP risk in individuals on CBZ or LTG. Studies were categorized according to whether idiopathic generalized epilepsy (IGE) or females were considered separately, and whether data were adjusted for seizure frequency. Eight studies on CBZ and six studies on LTG were identified. For CBZ, one study showed a significantly increased risk of SUDEP without adjustment for seizure frequency. Another study found significantly increased risk after statistical adjustment for seizure frequency and one study found increased risk with high blood levels. Five other studies found no increase in risk. For LTG, one study showed a significantly increased risk in patients with IGE as opposed to focal epilepsy, and another study showed a significantly increased risk in females. None of the subsequent studies on LTG and none of the studies on CBZ considered females with IGE separately. Taken together the available studies suggest that LTG, and possibly CBZ, may increase occurrence of SUDEP when used in females with IGE. Additional studies with sub-group analysis of females with IGE are needed.
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Affiliation(s)
- Dag Bruheim Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Giussani G, Falcicchio G, La Neve A, Costagliola G, Striano P, Scarabello A, Mostacci B, Beghi E. Sudden unexpected death in epilepsy: A critical view of the literature. Epilepsia Open 2023; 8:728-757. [PMID: 36896633 PMCID: PMC10472423 DOI: 10.1002/epi4.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus in which postmortem examination does not reveal other causes of death. Lower diagnostic levels are assigned when cases met most or all of these criteria, but data suggested more than one possible cause of death. The incidence of SUDEP ranged from 0.09 to 2.4 per 1000 person-years. Differences can be attributed to the age of the study populations (with peaks in the 20-40-year age group) and the severity of the disease. Young age, disease severity (in particular, a history of generalized TCS), having symptomatic epilepsy, and the response to antiseizure medications (ASMs) are possible independent predictors of SUDEP. The pathophysiological mechanisms are not fully known due to the limited data available and because SUDEP is not always witnessed and has been electrophysiologically monitored only in a few cases with simultaneous assessment of respiratory, cardiac, and brain activity. The pathophysiological basis of SUDEP may vary according to different circumstances that make that particular seizure, in that specific moment and in that patient, a fatal event. The main hypothesized mechanisms, which could contribute to a cascade of events, are cardiac dysfunction (included potential effects of ASMs, genetically determined channelopathies, acquired heart diseases), respiratory dysfunction (included postictal arousal deficit for the respiratory mechanism, acquired respiratory diseases), neuromodulator dysfunction, postictal EEG depression and genetic factors.
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Affiliation(s)
- Giorgia Giussani
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | | | - Pasquale Striano
- IRCCS Istituto “Giannina Gaslini”GenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Anna Scarabello
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
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Singh V, Ryan JM, Auerbach DS. It is premature for a unified hypothesis of sudden unexpected death in epilepsy: A great amount of research is still needed to understand the multisystem cascade. Epilepsia 2023; 64:2006-2010. [PMID: 37129136 DOI: 10.1111/epi.17636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 05/03/2023]
Affiliation(s)
- Veronica Singh
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Justin M Ryan
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
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Bagnall RD, Perucca P. ILAE Genetic Literacy Series: Postmortem Genetic Testing in Sudden Unexpected Death in Epilepsy. Epileptic Disord 2023; 25:472-479. [PMID: 37340991 DOI: 10.1002/epd2.20090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/31/2023] [Accepted: 06/17/2023] [Indexed: 06/22/2023]
Abstract
A 24-year-old man with non-lesional bitemporal lobe epilepsy since age 16 years was found dead in bed around midday. He was last seen the previous night when he was witnessed to have a tonic-clonic seizure. Before his death, he was experiencing weekly focal impaired awareness seizures and up to two focal-to-bilateral tonic-clonic seizures each year. He had trialed several antiseizure medications and was on levetiracetam 1500 mg/day, lamotrigine 400 mg/day, and clobazam 10 mg/day at the time of death. Other than epilepsy, his medical history was unremarkable. Of note, he had an older brother with a history of febrile seizures and a paternal first cousin with epilepsy. No cause of death was identified following a comprehensive postmortem investigation. The coroner classified the death as "sudden unexpected death in epilepsy" (SUDEP), and it would qualify as "definite SUDEP" using the current definitions.1 This left the family with many questions unanswered; in particular, they wish to know what caused the death and whether it could happen to other family members. Could postmortem genetic testing identify a cause of death, provide closure to the family, and facilitate cascade genetic testing of first-degree family members who may be at risk of sudden death? While grieving family members struggle with uncertainty about the cause of death, we as clinicians also face similar uncertainties about genetic contributions to SUDEP, especially when the literature is sparse, and the utility of genetic testing is still being worked out. We aim to shed some light on this topic, highlighting areas where data is emerging but also areas where uncertainty remains, keeping our case in mind as we examine this clinically important area.
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Affiliation(s)
- Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research Centre, The University of Melbourne, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Xu Y, Zhao L, Dong J, Jiang J, Jin L. Pathogenic SCN5A Mutation and Thyrotoxicosis-Related Neurological Syndrome: Casual or Causal Relationship? Brain Sci 2023; 13:1049. [PMID: 37508981 PMCID: PMC10377684 DOI: 10.3390/brainsci13071049] [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: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Various neurologic complications of hyperthyroidism are reported, and most of these complications are reversible with the amelioration of thyrotoxicosis. We report a previously undescribed concurrence of hyperthyroid-associated exercise-induced myalgia and stiffness, pyramidal tract dysfunction, and myoclonic movements that make an initial clinical diagnosis difficult. CASE PRESENTATION A 17-year-old male was hospitalized in the department of neurology, presenting with a 4-year history of severe exercise-induced myalgia and stiffness, weakness of lower limbs, and myoclonic movements. Laboratory investigations unexpectedly revealed hyperthyroidism. MRI of the brain and spine, electrophysiology, and whole exome sequencing were also performed. Antithyroid therapy led to marked improvement of neurologic symptoms, accompanied by a significant improvement of the time-dependent decline in compound muscle action potentials (CMAP) amplitudes after exercise and normalization of the prolonged QTc interval. Genetic analysis identified a rare variant in SCN5A. CONCLUSION This case report provides important insights into the relationship between hyperthyroidism and neurologic/cardiac complications, particularly in those with a genetic predisposition. SCN5A mutation possibly plays a role in the complex neurological syndrome associated with hyperthyroidism. Further studies are warranted to better understand the underlying mechanisms and potential therapeutic options for these complex conditions.
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Affiliation(s)
- Yangqi Xu
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Lin Zhao
- Department of Endocrinology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Jihong Dong
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Jingjing Jiang
- Department of Endocrinology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Lirong Jin
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200030, China
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Remme CA. SCN5A channelopathy: arrhythmia, cardiomyopathy, epilepsy and beyond. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220164. [PMID: 37122208 PMCID: PMC10150216 DOI: 10.1098/rstb.2022.0164] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/31/2022] [Indexed: 05/02/2023] Open
Abstract
Influx of sodium ions through voltage-gated sodium channels in cardiomyocytes is essential for proper electrical conduction within the heart. Both acquired conditions associated with sodium channel dysfunction (myocardial ischaemia, heart failure) as well as inherited disorders secondary to mutations in the gene SCN5A encoding for the cardiac sodium channel Nav1.5 are associated with life-threatening arrhythmias. Research in the last decade has uncovered the complex nature of Nav1.5 distribution, function, in particular within distinct subcellular subdomains of cardiomyocytes. Nav1.5-based channels furthermore display previously unrecognized non-electrogenic actions and may impact on cardiac structural integrity, leading to cardiomyopathy. Moreover, SCN5A and Nav1.5 are expressed in cell types other than cardiomyocytes as well as various extracardiac tissues, where their functional role in, e.g. epilepsy, gastrointestinal motility, cancer and the innate immune response is increasingly investigated and recognized. This review provides an overview of these novel insights and how they deepen our mechanistic knowledge on SCN5A channelopathies and Nav1.5 (dys)function. This article is part of the theme issue 'The heartbeat: its molecular basis and physiological mechanisms'.
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Affiliation(s)
- Carol Ann Remme
- Department of Experimental Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Heart Failure & Arrhythmias, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Gigli L, Sala S, Preda A, Okubo K, Peretto G, Frontera A, Varrenti M, Baroni M, Carbonaro M, Vargiu S, Di Resta C, Striano P, Mazzone P, Della Bella P. Electrocardiogram Changes in the Postictal Phase of Epileptic Seizure: Results from a Prospective Study. J Clin Med 2023; 12:4098. [PMID: 37373791 DOI: 10.3390/jcm12124098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The brain and heart are strictly linked and the electrical physiologies of these organs share common pathways and genes. Epilepsy patients have a higher prevalence of electrocardiogram (ECG) abnormalities compared to healthy people. Furthermore, the relationship between epilepsy, genetic arrhythmic diseases and sudden death is well known. The association between epilepsy and myocardial channelopathies, although already proposed, has not yet been fully demonstrated. The aim of this prospective observational study is to assess the role of the ECG after a seizure. MATERIALS AND METHODS From September 2018 to August 2019, all patients admitted to the emergency department of San Raffaele Hospital with a seizure were enrolled in the study; for each patient, neurological, cardiological and ECG data were collected. The ECG was performed at the time of the admission (post-ictal ECG) and 48 h later (basal ECG) and analyzed by two blinded expert cardiologists looking for abnormalities known to indicate channelopathies or arrhythmic cardiomyopathies. In all patients with abnormal post-ictal ECG, next generation sequencing (NGS) analysis was performed. RESULTS One hundred and seventeen patients were enrolled (females: 45, median age: 48 ± 12 years). There were 52 abnormal post-ictal ECGs and 28 abnormal basal ECGs. All patients with an abnormal basal ECG also had an abnormal post-ictal ECG. In abnormal post-ictal ECG, a Brugada ECG pattern (BEP) was found in eight patients (of which two had BEP type I) and confirmed in two basal ECGs (of which zero had BEP type I). An abnormal QTc interval was identified in 20 patients (17%), an early repolarization pattern was found in 4 patients (3%) and right precordial abnormalities were found in 5 patients (4%). Any kind modification of post-ictal ECG was significantly more pronounced in comparison with an ECG recorded far from the seizure (p = 0.003). A 10:1 higher prevalence of a BEP of any type (particularly in post-ictal ECG, p = 0.04) was found in our population compared to general population. In three patients with post-ictal ECG alterations diagnostic for myocardial channelopathy (BrS and ERP), not confirmed at basal ECG, a pathogenic gene variant was identified (KCNJ8, PKP2 and TRMP4). CONCLUSION The 12-lead ECG after an epileptic seizure may show disease-related alterations otherwise concealed in a population at a higher incidence of sudden death and channelopathies. Post-ictal BEP incidence was higher in cases of nocturnal seizure.
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Affiliation(s)
- Lorenzo Gigli
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Simone Sala
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Kenji Okubo
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka 238-8558, Japan
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | | | - Marisa Varrenti
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Matteo Baroni
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Marco Carbonaro
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Sara Vargiu
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Chiara Di Resta
- Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Genomic Unit for the Diagnosis of Human Pathologies, Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16126 Genoa, Italy
| | - Patrizio Mazzone
- De Gasperis Cardiocenter, Electrophisiology Unit, Niguarda Hospital, 20162 Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
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Yu C, Deng XJ, Xu D. Gene mutations in comorbidity of epilepsy and arrhythmia. J Neurol 2023; 270:1229-1248. [PMID: 36376730 DOI: 10.1007/s00415-022-11430-2] [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: 07/31/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
Epilepsy is one of the most common neurological disorders, and sudden unexpected death in epilepsy (SUDEP) is the most severe outcome of refractory epilepsy. Arrhythmia is one of the heterogeneous factors in the pathophysiological mechanism of SUDEP with a high incidence in patients with refractory epilepsy, increasing the risk of premature death. The gene co-expressed in the brain and heart is supposed to be the genetic basis between epilepsy and arrhythmia, among which the gene encoding ion channel contributes to the prevalence of "cardiocerebral channelopathy" theory. Nevertheless, this theory could only explain the molecular mechanism of comorbid arrhythmia in part of patients with epilepsy (PWE). Therefore, we summarized the mutant genes that can induce comorbidity of epilepsy and arrhythmia and the possible corresponding treatments. These variants involved the genes encoding sodium, potassium, calcium and HCN channels, as well as some non-ion channel coding genes such as CHD4, PKP2, FHF1, GNB5, and mitochondrial genes. The relationship between genotype and clinical phenotype was not simple linear. Indeed, genes co-expressed in the brain and heart could independently induce epilepsy and/or arrhythmia. Mutant genes in brain could affect cardiac rhythm through central or peripheral regulation, while in the heart it could also affect cerebral electrical activity by changing the hemodynamics or internal environment. Analysis of mutations in comorbidity of epilepsy and arrhythmia could refine and expand the theory of "cardiocerebral channelopathy" and provide new insights for risk stratification of premature death and corresponding precision therapy in PWE.
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Affiliation(s)
- Cheng Yu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Xue-Jun Deng
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Da Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China.
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The Anti-Epileptic Drugs Lamotrigine and Valproic Acid Reduce the Cardiac Sodium Current. Biomedicines 2023; 11:biomedicines11020477. [PMID: 36831014 PMCID: PMC9953282 DOI: 10.3390/biomedicines11020477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
Anti-epileptic drugs (AEDs) are associated with increased risk of sudden cardiac death. To establish whether gabapentin, lamotrigine, levetiracetam, pregabalin, and valproic acid reduce the Nav1.5 current, we conducted whole-cell patch-clamp studies to study the effects of the five AEDs on currents of human cardiac Nav1.5 channels stably expressed in HEK293 cells, and on action potential (AP) properties of freshly isolated rabbit ventricular cardiomyocytes. Lamotrigine and valproic acid exhibited inhibitory effects on the Nav1.5 current in a concentration-dependent manner with an IC50 of 142 ± 36 and 2022 ± 25 µM for lamotrigine and valproic acid, respectively. In addition, these drugs caused a hyperpolarizing shift of steady-state inactivation and a delay in recovery from inactivation. The changes on the Nav1.5 properties were reflected by a reduction in AP upstroke velocity (43.0 ± 6.8% (lamotrigine) and 23.7 ± 10.6% (valproic acid) at 1 Hz) and AP amplitude; in contrast, AP duration was not changed. Gabapentin, levetiracetam, and pregabalin had no effect on the Nav1.5 current. Lamotrigine and valproic acid reduce the Nav1.5 current density and affect its gating properties, resulting in a decrease of the AP upstroke velocity. Gabapentin, levetiracetam, and pregabalin have no effects on the Nav1.5 current.
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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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di Carlo KS, Cajat B. Crise comitiale et arrêt cardiaque secondaire à un syndrome du QT long. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Soh MS, Bagnall RD, Semsarian C, Scheffer IE, Berkovic SF, Reid CA. Rare SUDEP SCN5A variants cause changes in channel function implicating cardiac arrhythmia as a cause of death. Epilepsia 2022; 63:e57-e62. [PMID: 35397174 DOI: 10.1111/epi.17254] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/29/2022]
Abstract
Sudden Unexpected Death in Epilepsy (SUDEP) is a leading cause of premature death in epilepsy. The underlying pathological mechanisms are likely to be multi-factorial. Cardiac arrhythmia has been suggested as a cause of death in some patients with SUDEP. SCN5A encodes the cardiac Nav 1.5 sodium channel. SCN5A variants that result in either loss or gain of channel function cause cardiac arrhythmias. Rare SCN5A variants have been reported in SUDEP cases but the impact of these variants on channel function is unknown. Here we use whole-cell voltage clamp recordings to perform functional analyses of rare SCN5A SUDEP variants, p.V223G, p.I397V and p.R523C. Expression and biophysical properties including activation, inactivation and recovery from inactivation were probed. Each SCN5A variant significantly impacted human NaV 1.5 channel function indicating that they could cause cardiac arrhythmias. The patient carrying the p.R523C variant was on lamotrigine, an antiseizure medication implicated in SUDEP. Therapeutic concentration of lamotrigine caused a slowing of the rate of recovery from inactivation and a hyperpolarizing shift in the voltage of inactivation of human NaV 1.5 wild-type, but not p.R523C channels, implicating a gene-by-drug interaction. These data suggest that SCN5A arrhythmogenic variants may confer increased risk of sudden death in individuals with epilepsy.
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Affiliation(s)
- Ming S Soh
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Ingrid E Scheffer
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Royal Children's Hospital, VIC, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Christopher A Reid
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
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Abstract
INTRODUCTION Patients with severe epilepsy are at increased risk of cardiovascular disease and arrhythmias. Although antiseizure medications (ASMs) may have indirect protective effects against cardiovascular events by reducing seizure frequency and hence sudden death in epilepsy, some of them exert cardiotoxic effects. AREAS COVERED Patients with epilepsy, mainly those with severe forms, are at higher risk of cardiac disease because their heart can have structural alterations and electrical instability as a consequence of repeated seizures. Some ASMs have direct protective effects through anti-inflammatory, antioxidant, hypotensive, and lipid-reducing properties. Antiseizure medications can also have toxic cardiac effects including both long-term consequences, such as the increased risk of atherogenesis and subsequent cardiovascular disease due to the influence on lipid profile and pro-inflammatory milieu, and immediate effects as the increased risk of potentially fatal arrhythmias due to the influence on ion channels. Sodium channel blocking ASMs may also affect cardiac sodium channels and this effect is particularly observed in subjects with genetic mutations in cardiac ion channels. Fenfluramine cause valvulopathies in obese subjects and this effect need to be evaluated in epilepsy patients. EXPERT OPINION For the selection of treatment, cardiotoxic effects of ASMs should be considered; cardiac monitoring of treatment is advisable.
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Affiliation(s)
- Gaetano Zaccara
- Department of Eidemiology, Regional Health Agency of Tuscany, Firenze, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (Sabes-asdaa), Merano-Meran, Italy
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14
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Sahly AN, Shevell M, Sadleir LG, Myers KA. SUDEP risk and autonomic dysfunction in genetic epilepsies. Auton Neurosci 2021; 237:102907. [PMID: 34773737 DOI: 10.1016/j.autneu.2021.102907] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 10/11/2021] [Accepted: 11/06/2021] [Indexed: 01/02/2023]
Abstract
The underlying pathophysiology of sudden unexpected death in epilepsy (SUDEP) remains unclear. This phenomenon is likely multifactorial, and there is considerable evidence that genetic factors play a role. There are certain genetic causes of epilepsy in which the risk of SUDEP appears to be increased relative to epilepsy overall. For individuals with pathogenic variants in genes including SCN1A, SCN1B, SCN8A, SCN2A, GNB5, KCNA1 and DEPDC5, there are varying degrees of evidence to suggest an increased risk for sudden death. Why the risk for sudden death is higher is not completely clear; however, in many cases pathogenic variants in these genes are also associated with autonomic dysfunction, which is hypothesized as a contributing factor to SUDEP. We review the evidence for increased SUDEP risk for patients with epilepsy due to pathogenic variants in these genes, and also discuss what is known about autonomic dysfunction in these contexts.
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Affiliation(s)
- Ahmed N Sahly
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Department of Neurosciences, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Michael Shevell
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Medical Centre, Montreal, Quebec, Canada
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Kenneth A Myers
- Division of Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of the McGill University Medical Centre, Montreal, Quebec, Canada.
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15
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D'Imperio S, Monasky MM, Micaglio E, Ciconte G, Anastasia L, Pappone C. Brugada Syndrome: Warning of a Systemic Condition? Front Cardiovasc Med 2021; 8:771349. [PMID: 34722688 PMCID: PMC8553994 DOI: 10.3389/fcvm.2021.771349] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
Brugada syndrome (BrS) is a hereditary disorder, characterized by a specific electrocardiogram pattern and highly related to an increased risk of sudden cardiac death. BrS has been associated with other cardiac and non-cardiac pathologies, probably because of protein expression shared by the heart and other tissue types. In fact, the most commonly found mutated gene in BrS, SCN5A, is expressed throughout nearly the entire body. Consistent with this, large meals and alcohol consumption can trigger arrhythmic events in patients with BrS, suggesting a role for organs involved in the digestive and metabolic pathways. Ajmaline, a drug used to diagnose BrS, can have side effects on non-cardiac tissues, such as the liver, further supporting the idea of a role for organs involved in the digestive and metabolic pathways in BrS. The BrS electrocardiogram (ECG) sign has been associated with neural, digestive, and metabolic pathways, and potential biomarkers for BrS have been found in the serum or plasma. Here, we review the known associations between BrS and various organ systems, and demonstrate support for the hypothesis that BrS is not only a cardiac disorder, but rather a systemic one that affects virtually the whole body. Any time that the BrS ECG sign is found, it should be considered not a single disease, but rather the final step in any number of pathways that ultimately threaten the patient's life. A multi-omics approach would be appropriate to study this syndrome, including genetics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and glycomics, resulting eventually in a biomarker for BrS and the ability to diagnose this syndrome using a minimally invasive blood test, avoiding the risk associated with ajmaline testing.
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Affiliation(s)
- Sara D'Imperio
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Michelle M Monasky
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Emanuele Micaglio
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Giuseppe Ciconte
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Luigi Anastasia
- Faculty of Medicine and Surgery, University of Vita-Salute San Raffaele, Milan, Italy
| | - Carlo Pappone
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy.,Faculty of Medicine and Surgery, University of Vita-Salute San Raffaele, Milan, Italy
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16
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Costagliola G, Orsini A, Coll M, Brugada R, Parisi P, Striano P. The brain-heart interaction in epilepsy: implications for diagnosis, therapy, and SUDEP prevention. Ann Clin Transl Neurol 2021; 8:1557-1568. [PMID: 34047488 PMCID: PMC8283165 DOI: 10.1002/acn3.51382] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/15/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022] Open
Abstract
The influence of the central nervous system and autonomic system on cardiac activity is being intensively studied, as it contributes to the high rate of cardiologic comorbidities observed in people with epilepsy. Indeed, neuroanatomic connections between the brain and the heart provide links that allow cardiac arrhythmias to occur in response to brain activation, have been shown to produce arrhythmia both experimentally and clinically. Moreover, seizures may induce a variety of transient cardiac effects, which include changes in heart rate, heart rate variability, arrhythmias, asystole, and other ECG abnormalities, and can trigger the development of Takotsubo syndrome. People with epilepsy are at a higher risk of death than the general population, and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Although the cause of SUDEP is still unknown, cardiac abnormalities during and between seizures could play a significant role in its pathogenesis, as highlighted by studies on animal models of SUDEP and registration of SUDEP events. Recently, genetic mutations in genes co-expressed in the heart and brain, which may result in epilepsy and cardiac comorbidity/increased risk for SUDEP, have been described. Recognition and a better understanding of brain-heart interactions, together with new advances in sequencing techniques, may provide new insights into future novel therapies and help in the prevention of cardiac dysfunction and sudden death in epileptic individuals.
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Affiliation(s)
- Giorgio Costagliola
- Pediatric Clinic, Santa Chiara's University Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandro Orsini
- Pediatric Clinic, Santa Chiara's University Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Monica Coll
- Cardiovascular Genetics Center, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain
| | - Ramon Brugada
- Cardiovascular Genetics Center, Institut d'Investigació Biomèdica de Girona (IDIBGI), Girona, Spain.,Medical Science Department, School of Medicine, University of Girona, Girona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Service, Hospital Josep Trueta, Girona, Spain
| | - Pasquale Parisi
- Chair of Pediatrics, NESMOS Department, Faculty of Medicine and Psychology, Sapienza University, Sant' Andrea Hospital, Rome, Italy
| | - Pasquale Striano
- IRCCS Istituto Giannina Gaslini, Genova, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
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17
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Soh MS, Bagnall RD, Bennett MF, Bleakley LE, Mohamed Syazwan ES, Phillips AM, Chiam MDF, McKenzie CE, Hildebrand M, Crompton D, Bahlo M, Semsarian C, Scheffer IE, Berkovic SF, Reid CA. Loss-of-function variants in K v 11.1 cardiac channels as a biomarker for SUDEP. Ann Clin Transl Neurol 2021; 8:1422-1432. [PMID: 34002542 PMCID: PMC8283159 DOI: 10.1002/acn3.51381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 01/14/2023] Open
Abstract
Objective To compare the frequency and impact on the channel function of KCNH2 variants in SUDEP patients with epilepsy controls comprising patients older than 50 years, a group with low SUDEP risk, and establish loss‐of‐function KCNH2 variants as predictive biomarkers of SUDEP risk. Methods We searched for KCNH2 variants with a minor allele frequency of <5%. Functional analysis in Xenopus laevis oocytes was performed for all KCNH2 variants identified. Results KCNH2 variants were found in 11.1% (10/90) of SUDEP individuals compared to 6.0% (20/332) of epilepsy controls (p = 0.11). Loss‐of‐function KCNH2 variants, defined as causing >20% reduction in maximal amplitude, were observed in 8.9% (8/90) SUDEP patients compared to 3.3% (11/332) epilepsy controls suggesting about threefold enrichment (nominal p = 0.04). KCNH2 variants that did not change channel function occurred at a similar frequency in SUDEP (2.2%; 2/90) and epilepsy control (2.7%; 9/332) cohorts (p > 0.99). Rare KCNH2 variants (<1% allele frequency) associated with greater loss of function and an ~11‐fold enrichment in the SUDEP cohort (nominal p = 0.03). In silico tools were unable to predict the impact of a variant on function highlighting the need for electrophysiological analysis. Interpretation These data show that loss‐of‐function KCNH2 variants are enriched in SUDEP patients when compared to an epilepsy population older than 50 years, suggesting that cardiac mechanisms contribute to SUDEP risk. We propose that genetic screening in combination with functional analysis can identify loss‐of‐function KCNH2 variants that could act as biomarkers of an individual’s SUDEP risk.
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Affiliation(s)
- Ming S Soh
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark F Bennett
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Lauren E Bleakley
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Erlina S Mohamed Syazwan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - A Marie Phillips
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,School of Biosciences, University of Melbourne, Melbourne, VIC, Australia
| | - Mathew D F Chiam
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Chaseley E McKenzie
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Michael Hildebrand
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Douglas Crompton
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia.,Neurology Department, Northern Health, Epping, VIC, Australia
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Ingrid E Scheffer
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, VIC, Australia
| | - Samuel F Berkovic
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
| | - Christopher A Reid
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
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18
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Monasky MM, Micaglio E, Locati ET, Pappone C. Evaluating the Use of Genetics in Brugada Syndrome Risk Stratification. Front Cardiovasc Med 2021; 8:652027. [PMID: 33969014 PMCID: PMC8096997 DOI: 10.3389/fcvm.2021.652027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/24/2021] [Indexed: 12/19/2022] Open
Abstract
The evolution of the current dogma surrounding Brugada syndrome (BrS) has led to a significant debate about the real usefulness of genetic testing in this syndrome. Since BrS is defined by a particular electrocardiogram (ECG) pattern, after ruling out certain possible causes, this disease has come to be defined more for what it is not than for what it is. Extensive research is required to understand the effects of specific individual variants, including modifiers, rather than necessarily grouping together, for example, “all SCN5A variants” when trying to determine genotype-phenotype relationships, because not all variants within a particular gene act similarly. Genetic testing, including whole exome or whole genome testing, and family segregation analysis should always be performed when possible, as this is necessary to advance our understanding of the genetics of this condition. All considered, BrS should no longer be considered a pure autosomal dominant disorder, but an oligogenic condition. Less common patterns of inheritance, such as recessive, X–linked, or mitochondrial may exist. Genetic testing, in our opinion, should not be used for diagnostic purposes. However, variants in SCN5A can have a prognostic value. Patients should be diagnosed and treated per the current guidelines, after an arrhythmologic examination, based on the presence of the specific BrS ECG pattern. The genotype characterization should come in a second stage, particularly in order to guide the familial diagnostic work-up. In families in which an SCN5A pathogenic variant is found, genetic testing could possibly contribute to the prognostic risk stratification.
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Affiliation(s)
| | - Emanuele Micaglio
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Emanuela T Locati
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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19
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Differential Methylation in the GSTT1 Regulatory Region in Sudden Unexplained Death and Sudden Unexpected Death in Epilepsy. Int J Mol Sci 2021; 22:ijms22062790. [PMID: 33801838 PMCID: PMC7999472 DOI: 10.3390/ijms22062790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/27/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022] Open
Abstract
Sudden cardiac death (SCD) is a diagnostic challenge in forensic medicine. In a relatively large proportion of the SCDs, the deaths remain unexplained after autopsy. This challenge is likely caused by unknown disease mechanisms. Changes in DNA methylation have been associated with several heart diseases, but the role of DNA methylation in SCD is unknown. In this study, we investigated DNA methylation in two SCD subtypes, sudden unexplained death (SUD) and sudden unexpected death in epilepsy (SUDEP). We assessed DNA methylation of more than 850,000 positions in cardiac tissue from nine SUD and 14 SUDEP cases using the Illumina Infinium MethylationEPIC BeadChip. In total, six differently methylated regions (DMRs) between the SUD and SUDEP cases were identified. The DMRs were located in proximity to or overlapping genes encoding proteins that are a part of the glutathione S-transferase (GST) superfamily. Whole genome sequencing (WGS) showed that the DNA methylation alterations were not caused by genetic changes, while whole transcriptome sequencing (WTS) showed that DNA methylation was associated with expression levels of the GSTT1 gene. In conclusion, our results indicate that cardiac DNA methylation is similar in SUD and SUDEP, but with regional differential methylation in proximity to GST genes.
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20
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Bleakley LE, Soh MS, Bagnall RD, Sadleir LG, Gooley S, Semsarian C, Scheffer IE, Berkovic SF, Reid CA. Are Variants Causing Cardiac Arrhythmia Risk Factors in Sudden Unexpected Death in Epilepsy? Front Neurol 2020; 11:925. [PMID: 33013630 PMCID: PMC7505992 DOI: 10.3389/fneur.2020.00925] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/17/2020] [Indexed: 12/25/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the most common cause of premature mortality in individuals with epilepsy. Acute and adaptive changes in heart rhythm in epilepsy implicate cardiac dysfunction as a potential pathogenic mechanism in SUDEP. Furthermore, variants in genes associated with Long QT syndrome (LQTS) have been identified in patients with SUDEP. LQTS is a cardiac arrhythmia condition that causes sudden cardiac death with strong similarities to SUDEP. Here, we discuss the possibility of an additive risk of death due to the functional consequences of a pathogenic variant in an LQTS gene interacting with seizure-mediated changes in cardiac function. Extending this general concept, we propose a hypothesis that common variants in LQTS genes, which cause a subtle impact on channel function and would not normally be considered risk factors for cardiac disease, may increase the risk of sudden death when combined with epilepsy. A greater understanding of the interaction between epilepsy, cardiac arrhythmia, and SUDEP will inform our understanding of SUDEP risk and subsequent potential prophylactic treatment.
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Affiliation(s)
- Lauren E Bleakley
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Ming S Soh
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | - Samuel Gooley
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology Centenary Institute, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ingrid E Scheffer
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia.,Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, VIC, Australia.,Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Samuel F Berkovic
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Christopher A Reid
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
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21
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Banfi P, Coll M, Oliva A, Alcalde M, Striano P, Mauri M, Princiotta L, Campuzano O, Versino M, Brugada R. Lamotrigine induced Brugada-pattern in a patient with genetic epilepsy associated with a novel variant in SCN9A. Gene 2020; 754:144847. [PMID: 32531456 DOI: 10.1016/j.gene.2020.144847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND A 30-year-old man presented with intellectual disability associated with epilepsy. The epilepsy was initially treated with sodium valproate and since he was 28 years-old with lamotrigine. With the addition of lamotrigine, a pattern of Brugada syndrome appeared on the electrocardiogram. The family history was positive for epilepsy from the motheŕs side, who had never been treated with lamotrigine. OBJECTIVE Determine the genetic cause of the intellectual disability, epilepsy and Brugada syndrome of the patient and try to establish a possible correlation between the genetic background and the Brugada syndrome pattern under lamotrigine treatment. METHODS A standard karyotype, array comparative genomic hybridization and two different NGS panels have done to the index case to identify the genetic causes of the intellectual disability, epilepsy and Brugada syndrome pattern. RESULTS Genetic analyses in the family identified a de novo duplication of 1.3 Mb in 8p21.3 as well as two novel heterozygous rare variants in SCN9A and AKAP9 genes, both inherited from the mother. CONCLUSION We hypothesize that in this family the SCN9A variant was responsible for the epileptic syndrome. In addition, given that SCN9A is lightly expressed in the heart tissue, we postulate that this SCN9A variant, alone or in combination with AKAP9 variant, might be responsible for the Brugada pattern when challenged by lamotrigine.
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Affiliation(s)
- P Banfi
- Neurology and Stroke Unit Divison, Circolo Hospital ASST Settelaghi University of Insubria Varese, Italy
| | - M Coll
- Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain
| | - A Oliva
- Institute of Public Health, Section of Legal Medicine, Catholic University, Rome, Italy
| | - M Alcalde
- Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain
| | - P Striano
- Pediatric Neurology and Muscular Diseases Unit, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, "G. Gaslini" Institute, Genova, Italy
| | - M Mauri
- Neurology and Stroke Unit Divison, Circolo Hospital ASST Settelaghi University of Insubria Varese, Italy
| | - L Princiotta
- Neurology and Stroke Unit Divison, Circolo Hospital ASST Settelaghi University of Insubria Varese, Italy
| | - O Campuzano
- Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - M Versino
- Neurology and Stroke Unit Divison, Circolo Hospital ASST Settelaghi University of Insubria Varese, Italy
| | - R Brugada
- Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain; Cardiology Service, Hospital JosepTrueta, University of Girona, Girona, Spain.
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22
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Ramos-Maqueda J, Bermúdez-Jiménez F, Ruiz RM, Ramos MC, Lerma MM, Millán PS, López MÁ, Sánchez LT, Jiménez-Jáimez J. Prognostic impact of misdiagnosis of cardiac channelopathies as epilepsy. PLoS One 2020; 15:e0231442. [PMID: 32298319 PMCID: PMC7161979 DOI: 10.1371/journal.pone.0231442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 03/10/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Cardiac channelopathies are a frequent cause of sudden cardiac death (SCD) and often manifest with convulsive syncope, leading to a misdiagnosis of epilepsy. We aim to evaluate the clinical impact of epilepsy misdiagnosis in a cohort of patients with cardiac channelopathies. METHODS Fifty probands/families with a cardiac channelopathy were included. We retrospectively collected information from medical records to identify all patients who presented with convulsive syncope and were diagnosed with epilepsy after neurological evaluation. Clinical data and outcome were compared with those of patients without a previous epilepsy diagnosis. RESULTS Eight patients had a previous diagnosis of epilepsy. At first episode, 3 of them presented a positive family history of SCD and 5 showed a pathological electrocardiogram; half presented with sudden cardiac arrest (SCA) and the rest with recurrent syncope despite treatment with 1 or more anti-epileptic drugs. Five patients had long QT syndrome, 2 had catecholaminergic polymorphic ventricular tachycardia, and 1 had Brugada syndrome. Epilepsy misdiagnosis was associated with an increased risk of SCA/SCD (OR 6.92, P = .04), a delay of 12 years (P = .047) in correct diagnosis, and a delay from first symptom to channelopathy diagnosis of 18.45 years (P < .0001). CONCLUSION Cardiac channelopathy patients can be misdiagnosed with epilepsy. This involves a delayed diagnosis, a delay from the first symptom to a correct diagnosis, and an increased risk of SCA/SCD.
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Affiliation(s)
- Javier Ramos-Maqueda
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Bermúdez-Jiménez
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Rosa Macías Ruiz
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | | | - Manuel Molina Lerma
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Pablo Sánchez Millán
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Miguel Álvarez López
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Luis Tercedor Sánchez
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
| | - Juan Jiménez-Jáimez
- Cardiology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
- Instituto de Investigación Biosanitaria de Granada, Granada, Spain
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23
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Strano S, Toni D, Ammirati F, Sanna T, Tomaino M, Brignole M, Mazza A, Nguyen BL, Di Bonaventura C, Ricci RP, Boriani G. Neuro-arrhythmology: a challenging field of action and research: a review from the Task Force of Neuro-arrhythmology of Italian Association of Arrhythmias and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2020; 20:731-744. [PMID: 31567632 DOI: 10.2459/jcm.0000000000000866] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
: There is a growing interest in the study of the mechanisms of heart and brain interactions with the aim to improve the management of high-impact cardiac rhythm disorders, first of all atrial fibrillation. However, there are several topics to which the scientific interests of cardiologists and neurologists converge constituting the basis for enhancing the development of neuro-arrhythmology. This multidisciplinary field should cover a wide spectrum of diseases, even beyond the classical framework corresponding to stroke and atrial fibrillation and include the complex issues of seizures as well as loss of consciousness and syncope. The implications of a more focused interaction between neurologists and cardiologists in the field of neuro-arrhythmology should include in perspective the institution of research networks specifically devoted to investigate 'from bench to bedside' the complex pathophysiological links of the abovementioned diseases, with involvement of scientists in the field of biochemistry, genetics, molecular medicine, physiology, pathology and bioengineering. An investment in the field could have important implications in the perspectives of a more personalized approach to patients and diseases, in the context of 'precision'medicine. Large datasets and electronic medical records, with the approach typical of 'big data' could enhance the possibility of new findings with potentially important clinical implications. Finally, the interaction between neurologists and cardiologists involved in arrythmia management should have some organizational implications, with new models of healthcare delivery based on multidisciplinary assistance, similarly to that applied in the case of syncope units.
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Affiliation(s)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome
| | | | - Tommaso Sanna
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Institute of Cardiology, Rome
| | - Marco Tomaino
- Department of Cardiology, Ospedale di Bolzano, Bolzano
| | - Michele Brignole
- Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna
| | - Andrea Mazza
- Cardiology Division, Santa Maria della Stella Hospital, Orvieto
| | | | | | | | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
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Barranco R, Caputo F, Molinelli A, Ventura F. Review on post-mortem diagnosis in suspected SUDEP: Currently still a difficult task for Forensic Pathologists. J Forensic Leg Med 2020; 70:101920. [PMID: 32090969 DOI: 10.1016/j.jflm.2020.101920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/21/2020] [Accepted: 02/01/2020] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Rosario Barranco
- Department of Legal and Forensic Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Fiorella Caputo
- Department of Legal and Forensic Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Andrea Molinelli
- Department of Legal and Forensic Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy
| | - Francesco Ventura
- Department of Legal and Forensic Medicine, University of Genova, Via De' Toni 12, 16132, Genova, Italy.
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25
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Ge Y, Ding D, Zhu G, Kwan P, Wang W, Hong Z, Sander JW. Genetic variants in incident SUDEP cases from a community-based prospective cohort with epilepsy. J Neurol Neurosurg Psychiatry 2020; 91:126-131. [PMID: 31776209 DOI: 10.1136/jnnp-2019-321983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/21/2019] [Accepted: 11/05/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is a leading cause of epilepsy-related mortality in young adults. It has been suggested that SUDEP may kill over 20 000 people with epilepsy in China yearly. The aetiology of SUDEP is unclear. Little is known about candidate genes for SUDEP in people of Chinese origin as most studies have ascertained this in Caucasians. No candidate genes for SUDEP in Chinese people have been identified. METHODS We performed whole exome sequencing (WES) in DNA samples collected from five incident cases of SUDEP identified in a large epilepsy cohort in rural China. We filtered rare variants identified from these cases as well as screened for SUDEP, epilepsy, heart disease or respiratory disease-related genes from previous published reports and compared them with publicly available data, living epilepsy controls and ethnicity-match non-epilepsy controls, to identify potential candidate genes for SUDEP. RESULTS After the filtering process, the five cases carried 168 qualified mutations in 167 genes. Among these genetic anomalies, we identified rare variants in SCN5A (1/5:20% in our cases), KIF6 (1/5:20% in our cases) and TBX18 (1/5:20% in our cases) which were absent in 330 living epilepsy control alleles from the same original cohort and 320 ethnicity-match non-epilepsy control alleles. CONCLUSIONS These three genes were previously related to heart disease, providing support to the hypothesis that underlying heart disorder may be a driver of SUDEP risk.
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Affiliation(s)
- Yan Ge
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ding Ding
- Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Fudan University, Shanghai, China
| | - Guoxing Zhu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Wenzhi Wang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zhen Hong
- Institute of Neurology, WHO Collaborating Center for Research and Training in Neurosciences, Huashan Hospital, Fudan University, Shanghai, China
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
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26
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Datta AN, Michoulas A, Guella I, Demos M. Two Patients With KCNT1-Related Epilepsy Responding to Phenobarbital and Potassium Bromide. J Child Neurol 2019; 34:728-734. [PMID: 31208268 DOI: 10.1177/0883073819854853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
KCNT1 encodes a sodium-activated potassium channel highly expressed in the brain, regulating hyperpolarization following repetitive firing. Mutations in KCNT1 were originally implicated in autosomal-dominant nocturnal frontal lobe epilepsy and epilepsy of infancy with migrating focal seizures. It is now known that there is variability in phenotypic expression and incomplete penetrance. We describe 2 patients with KCNT1-related epilepsy, one with epilepsy of infancy with migrating focal seizures and one with multifocal epilepsy. As most patients with KCNT1 variants have treatment-resistant epilepsy, drugs that specifically target the KCNT1 channel have been of great interest. Quinidine, a broad-spectrum potassium channel blocker, has shown promise; however, clinical trial results have been variable. Our patient with epilepsy of infancy with migrating focal seizures did not respond to a trial of quinidine at 6 weeks of age-one of the earliest reported quinidine trials in the literature for KCNT1-related epilepsy. This indicates that timing of treatment and response may not be related. Both patients responded to high-dose phenobarbital. The patient with epilepsy of infancy with migrating focal seizures also had a significant reduction in seizures with potassium bromide (KBr). Our data suggest that alternative therapies to quinidine should be considered as a therapeutic option for patients with KCNT1-related epilepsy. Although improved seizure control led to parent-reported improvements in neurodevelopment, it is unknown if phenobarbital and KBr impact the overall developmental trajectory of patients with KCNT1-related epilepsy. Further multicenter longitudinal studies are required.
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Affiliation(s)
- Anita N Datta
- 1 Division of Pediatric Neurology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aspasia Michoulas
- 1 Division of Pediatric Neurology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ilaria Guella
- 2 Centre for Applied Neurogenetics, University of British Columbia, Vancouver, British Columbia, Canada
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- 3 University of British Columbia, Vancouver, British Columbia, Canada.,EPGEN Study investigators include Shelin Adam, Cyrus Boelman, Corneliu Bolbocean, Sarah E. Buerki, Tara Candido, Patrice Eydoux, Daniel M. Evans, William Gibson, Gabriella Horvath, Linda Huh, Tanya N. Nelson, Graham Sinclair, Tamsin Tarling, Eric B. Toyota, Katelin N. Townsend, Margot I. Van Allen, Clara van Karnebeek, and Suzanne Vercauteren
| | - Michelle Demos
- 1 Division of Pediatric Neurology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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[Sudden unexpected death in epilepsy (SUDEP) : Epidemiology, cardiac and other risk factors]. Herzschrittmacherther Elektrophysiol 2019; 30:274-286. [PMID: 31489492 DOI: 10.1007/s00399-019-00643-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is one of the most frequent epilepsy-related causes of death. The incidence of SUDEP is estimated to be approximately 1.2/1000 person-years (PY); however, it varies considerably depending on disease-specific and demographic factors. The estimated incidence of SUDEP in children seems to be significantly lower (0.22/1000 PY) than in adults but recent studies in children (>12 years) indicated a similar incidence to that of adults. Based on these estimations, approximately 700 SUDEP cases would be expected in Germany annually but no reliable data or epidemiological studies on SUDEP are available. Various risk factors and predictors for SUDEP have been investigated, e.g. age, seizure frequency, number of antiepileptic drugs, non-compliance and comorbidities, with sometimes contradictory results. This is understandable given that the exact mechanisms of SUDEP are unclear; however, it is very likely that the frequency of (nocturnal) generalized tonic-clonic seizures is the most important risk factor. Nocturnal monitoring of seizures (using devices) or the presence of another person at night may represent important factors to reduce the risk of SUDEP. Thus, seizure control and seizure monitoring are, according to current knowledge, the most important factors to avoid SUDEP. Some recent studies have contributed to a better understanding of possible pathomechanisms of SUDEP; however, further research is needed to identify predictive clinical factors and biomarkers and in particular to prevent SUDEP.
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28
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Graziosi A, Pellegrino N, Di Stefano V, Raucci U, Luchetti A, Parisi P. Misdiagnosis and pitfalls in Panayiotopoulos syndrome. Epilepsy Behav 2019; 98:124-128. [PMID: 31369969 DOI: 10.1016/j.yebeh.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/19/2022]
Abstract
Panayiotopoulos syndrome (PS) is a frequent (6% among children of 1-15 years) and benign epileptic syndrome, characterized by predominantly autonomic symptoms (emesis, pallor, flushing, cyanosis, mydriasis/miosis, cardiorespiratory and thermoregulatory alterations, incontinence of urine and/or feces, hypersalivation, and modifications of intestinal motility) associated with simple motor focal seizures, which can be followed by secondary generalization. Panayiotopoulos syndrome can be extremely insidious, because it can mimic several condition, such as gastroenteritis, gastroesophageal reflux disease, encephalitis, syncope, migraine, sleep disorders, or even metabolic diseases. This peculiar pleiotropism should be kept in mind by child neurologists and pediatricians and general practitioners, because a wrong diagnosis may lead to inappropriate interventions. The consequences are high morbidity, costly mismanagement, and stress for children and their parents. The availability of electroencephalography (EEG) recording in pediatric Emergency Departments might be useful for a prompt and not-cost-consuming diagnosis. On the other hand, it is important to be aware of the possible, multifaceted, clinical presentations of PS and its clinical, radiological, and neurophysiological features in order to improve both recognition and management.
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Affiliation(s)
| | - Noemi Pellegrino
- Department of Pediatrics, "G. d'Annunzio" University, Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti, Italy
| | - Umberto Raucci
- Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Anna Luchetti
- Child Neurology, NESMOS Department, Faculty of Medicine & Psychology, "Sapienza" University, c/o Sant'Andrea Hospital, Rome, Italy
| | - Pasquale Parisi
- Child Neurology, NESMOS Department, Faculty of Medicine & Psychology, "Sapienza" University, c/o Sant'Andrea Hospital, Rome, Italy.
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Sanchez-Larsen A, Fernandez-Perez I, Principe A, Ley M, Rocamora R. SUDEP in Spain: An Epilepsy Monitoring Unit based case series. Seizure 2019; 69:258-264. [DOI: 10.1016/j.seizure.2019.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/28/2022] Open
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Coll M, Oliva A, Grassi S, Brugada R, Campuzano O. Update on the Genetic Basis of Sudden Unexpected Death in Epilepsy. Int J Mol Sci 2019; 20:ijms20081979. [PMID: 31018519 PMCID: PMC6515014 DOI: 10.3390/ijms20081979] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is a common neurological disorder associated with increased morbidity and mortality. Sudden unexpected death in epilepsy, also known as SUDEP, is the main cause of death in patients with epilepsy. SUDEP has an incidence of 1.2 per 1000 person-years in adults and 0.2 per 1000 person-years in children. SUDEP accounts for 8-17% of deaths in patients with epilepsy. It is commonly associated with a history of generalized tonic-clonic seizures, and its risk may be increased by other factors such as postictal electroencephalographic suppression, prone sleeping position, altered heart rate variability, conduction abnormalities, gender, or antiepileptic medications. Recently, electrocardiograms, electroencephalograms, and imaging markers have helped clinicians stratify SUDEP risk and identify patients in need of close monitoring. However, the pathophysiology of SUDEP is likely multifactorial and still unknown. Improving the knowledge of SUDEP incidence, risk factors, and biomarkers can help design and implement effective prevention strategies.
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Affiliation(s)
- Monica Coll
- Cardiovascular Genetics Center, University of Girona-IDIBGI, 17003 Salt, Spain.
| | - Antonio Oliva
- Section of Legal Medicine, Institute of Public Health, Catholic University, Fondazione Policlinico A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, 00168 Rome, Italy.
| | - Simone Grassi
- Section of Legal Medicine, Institute of Public Health, Catholic University, Fondazione Policlinico A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, 00168 Rome, Italy.
| | - Ramon Brugada
- Cardiovascular Genetics Center, University of Girona-IDIBGI, 17003 Salt, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain.
- Medical Science Department, School of Medicine, University of Girona, 17071 Girona, Spain.
- Cardiology Service, Hospital Josep Trueta, University of Girona, 17007 Girona, Spain.
| | - Oscar Campuzano
- Cardiovascular Genetics Center, University of Girona-IDIBGI, 17003 Salt, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain.
- Medical Science Department, School of Medicine, University of Girona, 17071 Girona, Spain.
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31
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DeGiorgio CM, Curtis A, Hertling D, Moseley BD. Sudden unexpected death in epilepsy: Risk factors, biomarkers, and prevention. Acta Neurol Scand 2019; 139:220-230. [PMID: 30443951 DOI: 10.1111/ane.13049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 01/01/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is one of the most important direct epilepsy-related causes of death, with an incidence in adults of 1.2 per 1000 person-years. Generalized tonic-clonic seizures have consistently emerged as the leading risk factor for SUDEP, particularly when such seizures are uncontrolled. High seizure burden, lack of antiepileptic drug (AED) treatment, polytherapy, intellectual disability, and prone position at the time of death are other key risk factors. Unfortunately, despite advances in treatment, overall mortality rates in epilepsy are rising. It is imperative that we learn more about SUDEP so that effective prevention strategies can be implemented. To help identify persons at greater risk of SUDEP and in need of closer monitoring, biomarkers are needed. Candidate biomarkers include electrocardiographic, electroencephalographic, and imaging abnormalities observed more frequently in those who have died suddenly and unexpectedly. As our knowledge of the pathophysiologic mechanisms behind SUDEP has increased, various preventative measures have been proposed. These include lattice pillows, postictal oxygen therapy, selective serotonin reuptake inhibitors, and inhibitors of opiate and adenosine receptors. Unfortunately, no randomized clinical trials are available to definitively conclude these measures are effective. Rather, gaining the best control of seizures possible (with AEDs, devices, and resective surgery) still remains the intervention with the best evidence to reduce the risk of SUDEP. In this evidence-based review, we explore the incidence of SUDEP and review the risk factors, biomarkers, and latest prevention strategies.
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Affiliation(s)
| | - Ashley Curtis
- Undergraduate Interdepartmental Program for Neuroscience, UCLA Los Angeles California
| | - Dieter Hertling
- Undergraduate Interdepartmental Program for Neuroscience, UCLA Los Angeles California
| | - Brian D. Moseley
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati Ohio
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32
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González A, Aurlien D, Haugaa KH, Taubøll E. Epilepsy in patients with long QT syndrome type 1: A Norwegian family. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:118-121. [PMID: 30406014 PMCID: PMC6215028 DOI: 10.1016/j.ebcr.2018.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 01/19/2023]
Abstract
The congenital long QT syndrome (cLQTS) is an inherited cardiac disorder and is associated with sudden cardiac death. We describe a Norwegian family with mutations within the KCNQ1 gene causing cLQTS type 1 (LQT1) and epilepsy. The index patient had Jervell and Lange-Nielsen-syndrome (JLNS) with deafness and recurrent episodes of cardiac arrhythmia. The mother and the brother have Romano-Ward syndrome (RWS) with recurrent arrhythmias. Whereas the father has focal epilepsy and genetically verified LQT1, the sister has both focal epilepsy and RWS. Our findings are consistent with the notion that mutations in the KCNQ1 gene can cause epilepsy. Mutations in the LQTS1 gene are associated with syncopes and sudden cardiac death. Our case report suggest that these mutations can also cause genuine epilepsy. Correct identification of this dual pathology may be of vital importance to patients. cLQTS should be considered a cardiocerebral channelopathy.
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Affiliation(s)
- Alba González
- Department of Neurology, Oslo University Hospital - Rikshospitalet, PO Box 4950, Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, PO Box 1072, Blindern, 0316 Oslo, Oslo, Norway
| | - Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, PO Box 8100, 4068 Stavanger, Norway
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital - Rikshospitalet, PO Box 4950, Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, PO Box 1072, Blindern, 0316 Oslo, Oslo, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital - Rikshospitalet, PO Box 4950, Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, PO Box 1072, Blindern, 0316 Oslo, Oslo, Norway
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González A, Aurlien D, Larsson PG, Olsen KB, Dahl IT, Edvardsen T, Haugaa KH, Taubøll E. Seizure-like episodes and EEG abnormalities in patients with long QT syndrome. Seizure 2018; 61:214-220. [DOI: 10.1016/j.seizure.2018.08.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/13/2018] [Accepted: 08/25/2018] [Indexed: 01/05/2023] Open
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34
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Ryvlin P, Ciumas C, Wisniewski I, Beniczky S. Wearable devices for sudden unexpected death in epilepsy prevention. Epilepsia 2018; 59 Suppl 1:61-66. [DOI: 10.1111/epi.14054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Carolina Ciumas
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
- Epilepsy Institute (IDEE); Lyon France
| | - Ilona Wisniewski
- Department of Clinical Neurosciences; CHUV; Lausanne Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology; Danish Epilepsy Center; Dianalund Denmark
- Department of Clinical Neurophysiology; Aarhus University Hospital; Aarhus Denmark
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35
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Ruthirago D, Julayanont P, Karukote A, Shehabeldin M, Nugent K. Sudden unexpected death in epilepsy: ongoing challenges in finding mechanisms and prevention. Int J Neurosci 2018; 128:1052-1060. [PMID: 29667458 DOI: 10.1080/00207454.2018.1466780] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose/aim of the study: To summarize recent studies on the pathophysiology and preventive strategies for SUDEP. Materials and methods: Databases and literature review. Results: Patients with epilepsy have a significantly higher risk of death than the general population. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of sudden death among patients with epilepsy. Despite on-going research, there are still deficits in our knowledge about the mechanisms, genetic factors, and prevention of SUDEP. Current evidence suggests that cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction are the major mechanisms of SUDEP, and animal models support the role of neurotransmitters, especially serotonin and adenosine, in pathophysiology of SUDEP. Several mutations in the neurocardiogenic channelopathy genes have been identified as a possible cause of epilepsy and increased SUDEP risk. The lack of awareness that SUDEP can be a potential cause of premature death has been found in several surveys. In addition, medical legal cases demonstrate the need for more education about this condition. Several preventive strategies to reduce SUDEP have been proposed, including effective seizure control, nocturnal supervision, seizure monitoring, devices to protect the airway, and selective serotonin reuptake inhibitors. Further research is needed to determine the efficacy of these interventions. Conclusions: The major mechanisms of SUDEP include cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction. Effective control of seizures is the only effective strategy to prevent SUDEP. Other preventive interventions require more research.
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Affiliation(s)
- Doungporn Ruthirago
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Parunyou Julayanont
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Amputch Karukote
- b Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Mohamed Shehabeldin
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Kenneth Nugent
- c Department of Internal Medicine , Texas Tech University Health Science Center , Lubbock , TX , USA
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Kim Y, Bravo E, Thirnbeck CK, Smith-Mellecker LA, Kim SH, Gehlbach BK, Laux LC, Zhou X, Nordli DR, Richerson GB. Severe peri-ictal respiratory dysfunction is common in Dravet syndrome. J Clin Invest 2018; 128:1141-1153. [PMID: 29329111 DOI: 10.1172/jci94999] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 01/04/2018] [Indexed: 11/17/2022] Open
Abstract
Dravet syndrome (DS) is a severe childhood-onset epilepsy commonly due to mutations of the sodium channel gene SCN1A. Patients with DS have a high risk of sudden unexplained death in epilepsy (SUDEP), widely believed to be due to cardiac mechanisms. Here we show that patients with DS commonly have peri-ictal respiratory dysfunction. One patient had severe and prolonged postictal hypoventilation during video EEG monitoring and died later of SUDEP. Mice with an Scn1aR1407X/+ loss-of-function mutation were monitored and died after spontaneous and heat-induced seizures due to central apnea followed by progressive bradycardia. Death could be prevented with mechanical ventilation after seizures were induced by hyperthermia or maximal electroshock. Muscarinic receptor antagonists did not prevent bradycardia or death when given at doses selective for peripheral parasympathetic blockade, whereas apnea, bradycardia, and death were prevented by the same drugs given at doses high enough to cross the blood-brain barrier. When given via intracerebroventricular infusion at a very low dose, a muscarinic receptor antagonist prevented apnea, bradycardia, and death. We conclude that SUDEP in patients with DS can result from primary central apnea, which can cause bradycardia, presumably via a direct effect of hypoxemia on cardiac muscle.
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Affiliation(s)
- YuJaung Kim
- Department of Neurology and.,Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, USA
| | | | | | | | - Se Hee Kim
- Division of Pediatric Neurology, Northwestern University, Chicago, Illinois, USA
| | | | - Linda C Laux
- Division of Pediatric Neurology, Northwestern University, Chicago, Illinois, USA
| | | | - Douglas R Nordli
- Division of Pediatric Neurology, Northwestern University, Chicago, Illinois, USA
| | - George B Richerson
- Department of Neurology and.,Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa, USA.,Neurology Service, Veterans Affairs Medical Center, Iowa City, Iowa, USA
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Wang J, Ou SW, Zhang ZY, Qiu B, Wang YJ. Molecular expression of multiple Nav1.5 splice variants in the frontal lobe of the human brain. Int J Mol Med 2017; 41:915-923. [PMID: 29207052 PMCID: PMC5752160 DOI: 10.3892/ijmm.2017.3286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 11/22/2017] [Indexed: 11/29/2022] Open
Abstract
Voltage-gated sodium channels serve an essential role in the initiation and propagation of action potentials for central neurons. Previous studies have demonstrated that two novel variants of Nav1.5, designated Nav1.5e and Nav1.5f, were expressed in the human brain cortex. To date, nine distinct sodium channel isoforms of Nav1.5 have been identified. In the present study, the expression of Nav1.5 splice variants in the frontal lobe of the human brain cortex was systematically investigated. The results demonstrated that wild Nav1.5 and its splice variants, Nav1.5c and Nav1.5e, were expressed in the frontal lobe of the human brain cortex. Nav1.5a, Nav1.5b and Nav1.5d splice variants were not detected. However, the expression level of different Nav1.5 variants was revealed to vary. The expression ratio of wild Nav1.5 vs. Nav1.5c and Nav1.5e was approximately 5:1 and 1:5, respectively. Immunochemistry results revealed that Nav1.5 immunoreactivity was predominantly in neuronal cell bodies and processes, including axons and dendrites, whereas little immunoreactivity was detected in the glial components. These results revealed that a minimum of four Nav1.5 splice variants are expressed in the frontal lobe of the human brain cortex. This indicates that the previously reported tetrodotoxin-resistant sodium current was a compound product of different Nav1.5 variants. The present study revealed that Nav1.5 channels have a more abundant expression in the human brain than previously considered. It also provided further insight into the complexity and functional significance of Nav1.5 channels in human brain neurons.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Shao-Wu Ou
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Zhi-Yong Zhang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Bo Qiu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Yun-Jie Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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Wang J, Ou SW, Wang YJ. Distribution and function of voltage-gated sodium channels in the nervous system. Channels (Austin) 2017; 11:534-554. [PMID: 28922053 DOI: 10.1080/19336950.2017.1380758] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Voltage-gated sodium channels (VGSCs) are the basic ion channels for neuronal excitability, which are crucial for the resting potential and the generation and propagation of action potentials in neurons. To date, at least nine distinct sodium channel isoforms have been detected in the nervous system. Recent studies have identified that voltage-gated sodium channels not only play an essential role in the normal electrophysiological activities of neurons but also have a close relationship with neurological diseases. In this study, the latest research findings regarding the structure, type, distribution, and function of VGSCs in the nervous system and their relationship to neurological diseases, such as epilepsy, neuropathic pain, brain tumors, neural trauma, and multiple sclerosis, are reviewed in detail.
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Affiliation(s)
- Jun Wang
- a Department of Neurosurgery , The First Hospital of China Medical University , Shenyang , P.R. China
| | - Shao-Wu Ou
- a Department of Neurosurgery , The First Hospital of China Medical University , Shenyang , P.R. China
| | - Yun-Jie Wang
- a Department of Neurosurgery , The First Hospital of China Medical University , Shenyang , P.R. China
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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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Bagnall RD, Crompton DE, Semsarian C. Genetic Basis of Sudden Unexpected Death in Epilepsy. Front Neurol 2017; 8:348. [PMID: 28775708 PMCID: PMC5517398 DOI: 10.3389/fneur.2017.00348] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
People with epilepsy are at heightened risk of sudden death compared to the general population. The leading cause of epilepsy-related premature mortality is sudden unexpected death in epilepsy (SUDEP). Postmortem investigation of people with SUDEP, including histological and toxicological analysis, does not reveal a cause of death, and the mechanisms of SUDEP remain largely unresolved. In this review we present the possible mechanisms underlying SUDEP, including respiratory dysfunction, cardiac arrhythmia and postictal generalized electroencephlogram suppression. Emerging studies in humans and animal models suggest there may be an underlying genetic basis to SUDEP in some cases. We will highlight a mounting body of evidence for the involvement of genetic risk factors in SUDEP, with a particular focus on the role of cardiac arrhythmia genes in SUDEP.
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Affiliation(s)
- Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Douglas E Crompton
- Department of Neurology, Northern Health, Melbourne, VIC, Australia.,Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Melbourne, VIC, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Madan N, Carvalho KS. Neurological Complications of Cardiac Disease. Semin Pediatr Neurol 2017; 24:3-13. [PMID: 28779863 DOI: 10.1016/j.spen.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article focuses on the complex interactions between the cardiovascular and neurologic systems. Initially, we focus on neurological complications in children with congenital heart disease both secondary to the underlying cardiac disease and complications of interventions. We later discuss diagnosis and management of common syncope syndromes with emphasis on vasovagal syncope. We also review the diagnosis, classification, and management of children and adolescents with postural orthostatic tachycardia syndrome. Lastly, we discuss long QT syndrome and sudden unexpected death in epilepsy (SUDEP), reviewing advances in genetics and current knowledge of pathophysiology of these conditions. This article attempts to provide an overview of these disorders with focus on pathophysiology, advances in molecular genetics, and current medical interventions.
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Affiliation(s)
- Nandini Madan
- From the Section of Cardiology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Karen S Carvalho
- Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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Determining factors of electrocardiographic abnormalities in patients with epilepsy: A case-control study. Epilepsy Res 2016; 129:106-116. [PMID: 28043059 DOI: 10.1016/j.eplepsyres.2016.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/28/2016] [Accepted: 12/16/2016] [Indexed: 11/21/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in young patients with epilepsy (PWE). Although its mechanisms are still poorly understood, they may include cardiorespiratory dysfunction. Standard 12-lead electrocardiograms (ECGs) were obtained from 62 consecutive patients (aged 18-66y) with a definite diagnosis of epilepsy, without seizures at the day of ECG, and 57 healthy controls matched for sex, age and body mass index (BMI). All ECGs were evaluated by a blinded board-certified cardiologist. Patients with symptomatic focal epilepsy represented 90.3% (N=56), of whom 56.4% (N=35) had temporal lobe epilepsy, with a mean duration of 22.02±14.96years of epilepsy. We observed more prolonged P-wave (p<0.0001) and PR interval (p=0.01) in patients than in controls. Additionally, longer QT intervals (p<0.01), pathologic QT dispersion (p<0.01) and left atrial overload (p<0.01) were more common in PWE. Multiple linear regression analysis evidenced age, gender and polytherapy as factors associated with altered ECG. Therefore, routine ECG should be requested in PWE, especially for males, increasing age and in polytherapy. Findings such as longer PR and QT interval, and pathologic QT dispersion, may reflect cardiac structural changes and/or autonomic nervous system dysfunction and indicate a risk for SUDEP.
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Aurlien D, Gjerstad L, Taubøll E. The role of antiepileptic drugs in sudden unexpected death in epilepsy. Seizure 2016; 43:56-60. [PMID: 27886630 DOI: 10.1016/j.seizure.2016.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/26/2016] [Accepted: 11/05/2016] [Indexed: 01/30/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) primarily affects young adults and is the leading cause of death related directly to seizures. High frequency of generalized tonic-clonic seizures is the most important risk factor, and effective seizure protection is probably the most important measure to prevent these tragic deaths. For several years a potential role of antiepileptic drugs (AEDs) has been discussed, but at present there is wide agreement that choice of AED therapy does not influence the risk. However, although it is well known that the efficacy and safety profiles of AEDs may differ significantly when used in the treatment of genetic epilepsy compared to symptomatic or cryptogenic epilepsy, this has generally been overlooked in epidemiologic studies of possible relationships between AEDs and SUDEP. Consequently important information about drug safety may have been lost. This review challenges the current view that no AED can increase the risk of SUDEP.
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Affiliation(s)
- Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
| | - Leif Gjerstad
- Department of Neurology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
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The heart of epilepsy: Current views and future concepts. Seizure 2016; 44:176-183. [PMID: 27843098 DOI: 10.1016/j.seizure.2016.10.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/03/2016] [Indexed: 12/16/2022] Open
Abstract
Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.
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Jones LA, Thomas RH. Sudden death in epilepsy: Insights from the last 25 years. Seizure 2016; 44:232-236. [PMID: 27773556 DOI: 10.1016/j.seizure.2016.10.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/03/2016] [Indexed: 12/22/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of mortality in patients with refractory epilepsy, and as such has been a major research focus over the last 25 years. The earliest SUDEP research papers were published in Seizure, as have scores of SUDEP papers since. In this review we discuss the efforts to try and describe the pathophysiological basis of SUDEP, the drive to discover the clinical risk factors that increase the likelihood of SUDEP, and the motivation to increase awareness of SUDEP. These three areas are the prime factors that, when answered, will allow us to better mitigate against SUDEP and help individuals monitor their personal risk. The field has benefited from strong definitions, multinational collaboration, the use of cutting edge genetic analysis, and ensuring that bereaved families are able to take part in research when this is appropriate. Clearly there is much that we do not know and yet, has any area of epilepsy research come so far in the last 25 years?
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Affiliation(s)
- Lliwen A Jones
- Department of Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom
| | - Rhys H Thomas
- Department of Neurology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom; Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Hadyn Ellis Building, Maindy Road, Cardiff CF24 4HQ, United Kingdom.
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46
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Ravindran K, Powell KL, Todaro M, O'Brien TJ. The pathophysiology of cardiac dysfunction in epilepsy. Epilepsy Res 2016; 127:19-29. [PMID: 27544485 DOI: 10.1016/j.eplepsyres.2016.08.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 08/07/2016] [Accepted: 08/10/2016] [Indexed: 11/15/2022]
Abstract
Alterations in cardiac electrophysiology are an established consequence of long-standing drug resistant epilepsy. Patients with chronic epilepsy display abnormalities in both sinoatrial node pacemaker current as well as ventricular repolarizing current that places them at a greater risk of developing life-threatening cardiac arrhythmias. The development of cardiac arrhythmias secondary to drug resistant epilepsy is believed to be a key mechanism underlying the phenomenon of Sudden Unexpected Death in EPilepsy (SUDEP). Though an increasing amount of studies examining both animal models and human patients have provided evidence that chronic epilepsy can detrimentally affect cardiac function, the underlying pathophysiology remains unclear. Recent work has shown the expression of several key cardiac ion channels to be altered in animal models of genetic and acquired epilepsies. This has led to the currently held paradigm that cardiac ion channel expression may be secondarily altered as a consequence of seizure activity-resulting in electrophysiological cardiac dysfunction. Furthermore, cortical autonomic dysfunction - resulting from seizure activity-has also been suggested to play a role, whereby seizure activity may indirectly influence cardiac function via altering centrally-mediated autonomic output to the heart. In this review, we discuss various cardiac dysrhythmias associated with seizure events-including tachycardia, bradycardia and QT prolongation, both ictally and inter-ictally, as well as the role of the autonomic nervous system. We further discuss key ion channels expressed in both the heart and the brain that have been shown to be altered in epilepsy and may be responsible for the development of cardiac dysrhythmias secondary to chronic epilepsy.
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Affiliation(s)
- Krishnan Ravindran
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia.
| | - Kim L Powell
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Marian Todaro
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Terence J O'Brien
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia.
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47
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Taggart P, Critchley H, van Duijvendoden S, Lambiase PD. Significance of neuro-cardiac control mechanisms governed by higher regions of the brain. Auton Neurosci 2016; 199:54-65. [DOI: 10.1016/j.autneu.2016.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 12/24/2022]
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48
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Goldman AM, Behr ER, Semsarian C, Bagnall RD, Sisodiya S, Cooper PN. Sudden unexpected death in epilepsy genetics: Molecular diagnostics and prevention. Epilepsia 2016; 57 Suppl 1:17-25. [PMID: 26749013 DOI: 10.1111/epi.13232] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 12/19/2022]
Abstract
Epidemiologic studies clearly document the public health burden of sudden unexpected death in epilepsy (SUDEP). Clinical and experimental studies have uncovered dynamic cardiorespiratory dysfunction, both interictally and at the time of sudden death due to epilepsy. Genetic analyses in humans and in model systems have facilitated our current molecular understanding of SUDEP. Many discoveries have been informed by progress in the field of sudden cardiac death and sudden infant death syndrome. It is becoming apparent that SUDEP genomic complexity parallels that of sudden cardiac death, and that there is a pauci1ty of analytically useful postmortem material. Because many challenges remain, future progress in SUDEP research, molecular diagnostics, and prevention rests in international, collaborative, and transdisciplinary dialogue in human and experimental translational research of sudden death.
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Affiliation(s)
- Alica M Goldman
- Department of Neurology, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Elijah R Behr
- Cardiac Research Centre, ICCS, St George's University of London, London, United Kingdom
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sanjay Sisodiya
- Institute of Neurology, University College London, London, United Kingdom
| | - Paul N Cooper
- Department of Neurology, Greater Manchester Neurosciences Centre, Salford, United Kingdom.,University of Manchester, Manchester, United Kingdom
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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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