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Iyer SH, Hinman JE, Warren T, Matthews SA, Simeone TA, Simeone KA. Altered ventilatory responses to hypercapnia-hypoxia challenges in a preclinical SUDEP model involve orexin neurons. Neurobiol Dis 2024; 199:106592. [PMID: 38971479 DOI: 10.1016/j.nbd.2024.106592] [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: 12/22/2023] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 07/08/2024] Open
Abstract
Failure to recover from repeated hypercapnia and hypoxemia (HH) challenges caused by severe GCS and postictal apneas may contribute to sudden unexpected death in epilepsy (SUDEP). Our previous studies found orexinergic dysfunction contributes to respiratory abnormalities in a preclinical model of SUDEP, Kcna1-/- mice. Here, we developed two gas challenges consisting of repeated HH exposures and used whole body plethysmography to determine whether Kcna1-/- mice have detrimental ventilatory responses. Kcna1-/- mice exhibited an elevated ventilatory response to a mild repeated hypercapnia-hypoxia (HH) challenge compared to WT. Moreover, 71% of Kcna1-/- mice failed to survive a severe repeated HH challenge, whereas all WT mice recovered. We next determined whether orexin was involved in these differences. Pretreating Kcna1-/- mice with a dual orexin receptor antagonist rescued the ventilatory response during the mild challenge and all subjects survived the severe challenge. In ex vivo extracellular recordings in the lateral hypothalamus of coronal brain slices, we found reducing pH either inhibits or stimulates putative orexin neurons similar to other chemosensitive neurons; however, a significantly greater percentage of putative orexin neurons from Kcna1-/-mice were stimulated and the magnitude of stimulation was increased resulting in augmentation of the calculated chemosensitivity index relative to WT. Collectively, our data suggest that increased chemosensitive activity of orexin neurons may be pathologic in the Kcna1-/- mouse model of SUDEP, and contribute to elevated ventilatory responses. Our preclinical data suggest that those at high risk for SUDEP may be more sensitive to HH challenges, whether induced by seizures or other means; and the depth and length of the HH exposure could dictate the probability of survival.
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Affiliation(s)
- Shruthi H Iyer
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Jillian E Hinman
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Ted Warren
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Stephanie A Matthews
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Timothy A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA
| | - Kristina A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE 68178, USA.
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Granthon C, Tranberg AE, Malmgren K, Strandberg MC, Kumlien E, Redfors P. Reduced long-term mortality after successful resective epilepsy surgery: a population-based study. J Neurol Neurosurg Psychiatry 2024; 95:249-255. [PMID: 37734927 DOI: 10.1136/jnnp-2023-331417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND We investigated all-cause and epilepsy-related mortality in patients operated with resective epilepsy surgery and in non-operated patients with drug-resistant epilepsy. Our hypothesis was that patients who proceed to surgery have lower mortality over time compared with non-operated patients. METHOD Data from 1329 adults and children from the Swedish National Epilepsy Surgery Register and 666 patients with drug-resistant epilepsy who had undergone presurgical work-up but not been operated were analysed. The operated patients had follow-ups between 2 and 20 years. We used the Swedish Cause of Death Register to identify deaths. Autopsy reports were collected for patients with suspected sudden unexpected death in epilepsy (SUDEP). Kaplan-Meier and Cox regression analyses were performed to identify predictors for mortality and SUDEP. RESULTS SUDEP accounted for 30% of all deaths. Surgery was associated with lower all-cause mortality (HR 0.7, 95% CI 0.5 to 0.9), also when adjusted for age, sex and tonic-clonic seizures at inclusion. The benefit of surgery seemed to persist and possibly even increase after 15 years of follow-up. Risk factors of mortality for operated patients were persisting seizures and living alone. Of the operated patients, 37% had seizures, and these had a higher risk of mortality (HR 2.1, 95% CI 1.4 to 3.0) and SUDEP (HR 3.5, 95% CI 1.7 to 7.3) compared with patients with seizure freedom at last follow-up. CONCLUSIONS In this large population-based epilepsy surgery cohort, operated patients had a lower all-cause mortality compared with non-operated patients with drug-resistant epilepsy. Seizure freedom was the most important beneficial factor for both all-cause mortality and SUDEP among operated patients.
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Affiliation(s)
- Cecilia Granthon
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Edelvik Tranberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Malmgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Eva Kumlien
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Member of the ERN EpiCARE, Sahlgrenska University Hospital, Gothenburg, Sweden
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Swor D, Juneja P, Constantine C, Mann C, Rosenow F, LaRoche S. Management of status epilepticus in pregnancy: a clinician survey. Neurol Res Pract 2024; 6:3. [PMID: 38233889 PMCID: PMC10795404 DOI: 10.1186/s42466-023-00295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/26/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Status epilepticus in pregnancy (SEP) is rare and life-threatening for both mother and fetus. There are well-established guidelines for the management of women with epilepsy during pregnancy; however, there is little evidence guiding the management of SEP, leading to uncertainty among treating physicians. Therefore, this survey aims to investigate the real-world practices of physicians treating SEP to explore management approaches for improvements in care. METHODS An anonymous, electronic survey was created and distributed to neurointensivists and neurologists between September and December 2021. RESULTS One hundred physicians initiated the survey and 95 completed it in full: 87 (87%, 87/100) identified neurology as their primary specialty, 31 had subspecialty training in neurocritical care, and 48 had subspecialty training in epilepsy and/or clinical neurophysiology. Over half of the survey respondents (67%, 67/100) reported having participated in the management of SEP, with 48.9% (49/98) having done so in the past year. Most survey respondents (73%, 73/100) reported that their management approach to SEP is different than that of non-pregnant patients. Survey respondents were more likely to involve epilepsy consultants when treating SEP (58.5%, 58/99) and the vast majority involved Obstetrics/Maternal Fetal Medicine consultants (90.8%, 89/98). Survey respondents showed a clear preference for levetiracetam (89.7%, 87/97) in the treatment of benzodiazepine refractory status epilepticus followed by lacosamide (61%, 60/98) if an additional second line agent was needed. Valproate and phenobarbital were unlikely to be used. There was less agreement for the management of refractory and super-refractory SEP. CONCLUSIONS Levetiracetam is the most frequently used anti-seizure medication (ASM) for benzodiazepine-refractory SEP. Survey participants tended to manage SEP differently than in non-pregnant patients including greater involvement of interdisciplinary teams as well as avoidance of ASMs associated with known teratogenicity.
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Affiliation(s)
- Dionne Swor
- Department of Neurology, University of Toledo, Toledo, USA.
| | - Pallavi Juneja
- Department of Neurology, Columbia University, New York, USA
| | | | - Catrin Mann
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, Goethe University Frankfurt, Frankfurt, Germany
| | - Felix Rosenow
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main, Goethe University Frankfurt, Frankfurt, Germany
| | - Suzette LaRoche
- Department of Neurology, University of North Carolina, Chapel Hill, USA
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4
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Lin R, Lei M, Ding S, Cheng Q, Ma Z, Wang L, Tang Z, Zhou B, Zhou Y. Applications of flexible electronics related to cardiocerebral vascular system. Mater Today Bio 2023; 23:100787. [PMID: 37766895 PMCID: PMC10519834 DOI: 10.1016/j.mtbio.2023.100787] [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: 06/06/2023] [Revised: 08/14/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
Ensuring accessible and high-quality healthcare worldwide requires field-deployable and affordable clinical diagnostic tools with high performance. In recent years, flexible electronics with wearable and implantable capabilities have garnered significant attention from researchers, which functioned as vital clinical diagnostic-assisted tools by real-time signal transmission from interested targets in vivo. As the most crucial and complex system of human body, cardiocerebral vascular system together with heart-brain network attracts researchers inputting profuse and indefatigable efforts on proper flexible electronics design and materials selection, trying to overcome the impassable gulf between vivid organisms and rigid inorganic units. This article reviews recent breakthroughs in flexible electronics specifically applied to cardiocerebral vascular system and heart-brain network. Relevant sensor types and working principles, electronics materials selection and treatment methods are expounded. Applications of flexible electronics related to these interested organs and systems are specially highlighted. Through precedent great working studies, we conclude their merits and point out some limitations in this emerging field, thus will help to pave the way for revolutionary flexible electronics and diagnosis assisted tools development.
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Affiliation(s)
- Runxing Lin
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
- Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Ming Lei
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
| | - Sen Ding
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
| | - Quansheng Cheng
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
| | - Zhichao Ma
- Institute of Medical Robotics, School of Biomedical Engineering, Shanghai Jiao Tong University, No.800 Dongchuan Road, Shanghai, 200240, China
| | - Liping Wang
- Brain Cognition and Brain Disease Institute, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Zikang Tang
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
| | - Bingpu Zhou
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
| | - Yinning Zhou
- Joint Key Laboratory of the Ministry of Education, Institute of Applied Physics and Materials Engineering, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
- Department of Physics and Chemistry, Faculty of Science and Technology, University of Macau, Avenida da Universidade, Taipa, Macau, 999078, China
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Manis AD, Cook-Snyder DR, Duffy E, Osmani WA, Eilbes M, Dillard M, Palygin O, Staruschenko A, Hodges MR. Repeated seizures lead to progressive ventilatory dysfunction in SS Kcnj16-/- rats. J Appl Physiol (1985) 2023; 135:872-885. [PMID: 37535709 PMCID: PMC10642517 DOI: 10.1152/japplphysiol.00072.2023] [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: 02/06/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023] Open
Abstract
Patients with uncontrolled epilepsy experience repeated seizures putting them at increased risk for sudden unexpected death in epilepsy (SUDEP). Data from human patients have led to the hypothesis that SUDEP results from severe cardiorespiratory suppression after a seizure, which may involve pathological deficiencies in the brainstem serotonin (5-HT) system. Rats with a genomic Kcnj16 mutation (SSKcnj16-/- rats) are susceptible to sound-induced generalized tonic-clonic seizures (GTCS) which, when repeated once daily for up to 10 days (10-day seizure protocol), increased mortality, particularly in male rats. Here, we test the hypothesis that repeated seizures across the 10-day protocol will cause a progressive ventilatory dysfunction due to time-dependent 5-HT deficiency. Initial severe seizures led to ictal and postictal apneas and transient decreases in breathing frequency, ventilatory drive, breath-to-breath variability, and brief hypoventilation. These seizure-induced effects on ventilation were exacerbated with increasing seizures and ventilatory chemoreflexes became further impaired after repeated seizures. Tissue analyses of key brainstem regions controlling breathing showed time-dependent 5-HT system suppression and increased immunoreactivity for IBA-1 (microglial marker) without changes in overall cell counts at 3, 7, and 10 days of seizures. Fluoxetine treatment in SSKcnj16-/- rats prevented repeated seizure-induced progressive respiratory suppression but failed to prevent seizure-related mortality. We conclude that repeated seizures cause a progressive compromise of ventilatory control in the immediate postictal period largely mediated by serotonin system suppression in brainstem regions of respiratory control. However, other unknown factors contribute to overall survival following repeated seizures in this model.NEW & NOTEWORTHY This study demonstrated that repeated seizures in a novel rat model (SSKcnj16-/- rats) caused a progressively greater ventilatory dysfunction in the immediate postictal period associated with brainstem serotonin (5-HT) suppression. Augmenting brain 5-HT with a selective serotonin reuptake inhibitor prevented the progressive ventilatory dysfunction induced by repeated seizures but failed to prevent seizure-related mortality, suggesting that repeated seizures may lead to cardiorespiratory suppression and failure through multiple mechanisms.
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Affiliation(s)
- Anna D Manis
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Denise R Cook-Snyder
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Erin Duffy
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Wasif A Osmani
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Melissa Eilbes
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Matthew Dillard
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Oleg Palygin
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Alexander Staruschenko
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Department of Molecular Pharmacology & Physiology, University of South Florida, Tampa, Florida, United States
- James A. Haley Veterans' Hospital, Tampa, Florida, United States
| | - Matthew R Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Du Y, Fang W, Huang W, Xu Q, Gong J, Xia N, Zhu Z, Wang X, Zheng R, Xu H. Changes in seizure frequency and anti-seizure medication therapy during pregnancy and one year postpregnancy. Epilepsy Behav 2023; 144:109256. [PMID: 37244219 DOI: 10.1016/j.yebeh.2023.109256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
Seizure control in women with epilepsy (WWE) during pregnancy is a vital concern. The aim of this study was to compare changes in seizure frequency and anti-seizure medication (ASM ) therapy in WWE in a real-world setting over three epochs (prepregnancy, pregnancy, and postpregnancy). We screened WWE who were pregnant between 1 January 2010 and 31 December 2020 from the epilepsy follow-up registry database of a tertiary hospital in China. We reviewed and collected follow-up data for the following time periods: 12 months before pregnancy (epoch 1), throughout pregnancy and the first 6 weeks postpartum (epoch 2), and from 6 weeks to 12 months postpartum (epoch 3). Seizures were classified into two categories: tonic‒clonic/focal to bilateral tonic‒clonic seizures and non-tonic‒clonic seizures. The main indicator was the seizure-free rate over the three epochs. Using epoch 1 as a reference, we also compared the percentage of women with an increased seizure frequency, as well as changes in ASM treatment, in epochs 2 and 3. Ultimately, 271 eligible pregnancies in 249 women were included. The seizure-free rates in epoch 1, epoch 2, and epoch 3 were 38.4%, 34.7%, and 43.9%, respectively (P = 0.09). The top three ASMs used in the three epochs were lamotrigine, levetiracetam, and oxcarbazepine. Using epoch 1 as a reference, the percentages of women with increased frequencies of tonic‒clonic/focal to bilateral tonic‒clonic seizures in epoch 2 and epoch 3 were 17.0% and 14.8%, respectively, while the percentages of women with an increased frequency of non-tonic‒clonic seizures in epoch 2 and epoch 3 were 31.0% and 21.8% (P = 0.02). The percentage of women whose ASM dosages were increased in epoch 2 was higher than that in epoch 3 (35.8% vs. 27.3%, P = 0.03). The seizure frequency during pregnancy may not differ significantly from that during prepregnancy and postpregnancy if WWE are treated according to the guidelines.
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Affiliation(s)
- Yanru Du
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenqiang Fang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Wenting Huang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Qi Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Jiaoni Gong
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Niange Xia
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Zhenguo Zhu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Xinshi Wang
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Rongyuan Zheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
| | - Huiqin Xu
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, PR China.
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Ramirez JM, Carroll MS, Burgraff N, Rand CM, Weese-Mayer DE. A narrative review of the mechanisms and consequences of intermittent hypoxia and the role of advanced analytic techniques in pediatric autonomic disorders. Clin Auton Res 2023; 33:287-300. [PMID: 37326924 DOI: 10.1007/s10286-023-00958-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
Disorders of autonomic functions are typically characterized by disturbances in multiple organ systems. These disturbances are often comorbidities of common and rare diseases, such as epilepsy, sleep apnea, Rett syndrome, congenital heart disease or mitochondrial diseases. Characteristic of many autonomic disorders is the association with intermittent hypoxia and oxidative stress, which can cause or exaggerate a variety of other autonomic dysfunctions, making the treatment and management of these syndromes very complex. In this review we discuss the cellular mechanisms by which intermittent hypoxia can trigger a cascade of molecular, cellular and network events that result in the dysregulation of multiple organ systems. We also describe the importance of computational approaches, artificial intelligence and the analysis of big data to better characterize and recognize the interconnectedness of the various autonomic and non-autonomic symptoms. These techniques can lead to a better understanding of the progression of autonomic disorders, ultimately resulting in better care and management.
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Affiliation(s)
- Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, 1900 Ninth Avenue, Seattle, WA, 98101, USA.
- Departments of Neurological Surgery and Pediatrics, University of Washington School of Medicine, 1900 Ninth Avenue, Seattle, WA, 98101, USA.
| | - Michael S Carroll
- Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Autonomic Medicine, Stanley Manne Children's Research Institute at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Nicholas Burgraff
- Center for Integrative Brain Research, Seattle Children's Research Institute, 1900 Ninth Avenue, Seattle, WA, 98101, USA
| | - Casey M Rand
- Division of Autonomic Medicine, Stanley Manne Children's Research Institute at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Autonomic Medicine, Stanley Manne Children's Research Institute at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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8
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Micalizzi E, Vaudano AE, Ballerini A, Talami F, Giovannini G, Turchi G, Cioclu MC, Giunta L, Meletti S. Ictal apnea: A prospective monocentric study in patients with epilepsy. Eur J Neurol 2022; 29:3701-3710. [PMID: 36057450 PMCID: PMC9826458 DOI: 10.1111/ene.15547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 08/24/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Ictal respiratory disturbances have increasingly been reported, in both generalized and focal seizures, especially involving the temporal lobe. Recognition of ictal breathing impairment has gained importance for the risk of sudden unexpected death in epilepsy (SUDEP). The aim of this study was to evaluate the incidence of ictal apnea (IA) and related hypoxemia during seizures. METHODS We collected and analyzed electroclinical data from consecutive patients undergoing long-term video-electroencephalographic (video-EEG) monitoring with cardiorespiratory polygraphy. Patients were recruited at the epilepsy monitoring unit of the Civil Hospital of Baggiovara, Modena Academic Hospital, from April 2020 to February 2022. RESULTS A total of 552 seizures were recorded in 63 patients. IA was observed in 57 of 552 (10.3%) seizures in 16 of 63 (25.4%) patients. Thirteen (81.2%) patients had focal seizures, and 11 of 16 patients showing IA had a diagnosis of temporal lobe epilepsy; two had a diagnosis of frontal lobe epilepsy and three of epileptic encephalopathy. Apnea agnosia was reported in all seizure types. Hypoxemia was observed in 25 of 57 (43.9%) seizures with IA, and the severity of hypoxemia was related to apnea duration. Apnea duration was significantly associated with epilepsy of unknown etiology (magnetic resonance imaging negative) and with older age at epilepsy onset (p < 0.001). CONCLUSIONS Ictal respiratory changes are a frequent clinical phenomenon, more likely to occur in focal epilepsies, although detected even in patients with epileptic encephalopathy. Our findings emphasize the need for respiratory polygraphy during long-term video-EEG monitoring for diagnostic and prognostic purposes, as well as in relation to the potential link of ictal apnea with the SUDEP risk.
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Affiliation(s)
- Elisa Micalizzi
- Clinical and Experimental Medicine PhD ProgramUniversity of Modena and Reggio EmiliaModenaItaly,Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly
| | - Anna Elisabetta Vaudano
- Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly,Department of Biomedical, Metabolic, and Neural ScienceUniversity of Modena and Reggio EmiliaModenaItaly
| | - Alice Ballerini
- Department of Biomedical, Metabolic, and Neural ScienceUniversity of Modena and Reggio EmiliaModenaItaly
| | - Francesca Talami
- Department of Biomedical, Metabolic, and Neural ScienceUniversity of Modena and Reggio EmiliaModenaItaly
| | - Giada Giovannini
- Clinical and Experimental Medicine PhD ProgramUniversity of Modena and Reggio EmiliaModenaItaly,Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly
| | - Giulia Turchi
- Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly
| | - Maria Cristina Cioclu
- Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly,Department of Biomedical, Metabolic, and Neural ScienceUniversity of Modena and Reggio EmiliaModenaItaly
| | - Leandra Giunta
- Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly
| | - Stefano Meletti
- Neurology Unit, Civil Hospital of BaggiovaraModena Academic HospitalModenaItaly,Department of Biomedical, Metabolic, and Neural ScienceUniversity of Modena and Reggio EmiliaModenaItaly
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9
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Zhao H, Long L, Xiao B. Advances in sudden unexpected death in epilepsy. Acta Neurol Scand 2022; 146:716-722. [DOI: 10.1111/ane.13715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Haiting Zhao
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
| | - Lili Long
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
| | - Bo Xiao
- Department of Neurology Xiangya Hospital, Central South University Changsha China
- National Clinical Research Center for Geriatric Disorders Xiangya Hospital, Central South University Changsha China
- Clinical Research Center for Epileptic Disease of Hunan Province Central South University Changsha China
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10
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Karhu T, Leppänen T, Töyräs J, Oksenberg A, Myllymaa S, Nikkonen S. ABOSA - Freely available automatic blood oxygen saturation signal analysis software: Structure and validation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107120. [PMID: 36152624 DOI: 10.1016/j.cmpb.2022.107120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/04/2022] [Accepted: 09/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Many sleep recording software used in clinical settings have some tools to automatically analyze the blood oxygen saturation (SpO2) signal by detecting desaturations. However, these tools are often inadequate for scientific research as they do not provide SpO2 signal-based parameters which are superior in the estimation of sleep apnea severity and related medical consequences. In addition, these software require expensive licenses and they lack batch analysis tools. Thus, we developed the first freely available automatic blood oxygen saturation analysis software (ABOSA) that provides sophisticated SpO2 signal-based parameters and enables batch analysis of large datasets. METHODS ABOSA was programmed with MATLAB. ABOSA automatically detects desaturation and recovery events from the SpO2 signals (EDF files) and calculates numerous parameters, such as oxygen desaturation index (ODI) and desaturation severity (DesSev). The accuracy of the ABOSA software was evaluated by comparing its desaturation scorings to manual scorings in Kuopio (n = 1981) and Loewenstein (n = 930) sleep apnea patient datasets. Validation was performed in a second-by-second manner by calculating Matthew's correlation coefficients (MCC) and median differences in parameter values. Finally, the performance of the ABOSA software was compared to two commercial software, Noxturnal and Profusion, in 100 patient subpopulations. As Noxturnal or Profusion does not calculate novel desaturation parameters, these were calculated with custom-made functions. RESULTS The agreements between ABOSA and manual scorings were great in both Kuopio (MCC = 0.801) and Loewenstein (MCC = 0.898) datasets. However, ABOSA slightly overestimated the desaturation parameter values. The median differences in ODIs were 0.8 (Kuopio) and 0.0 (Loewenstein) events/h. Similarly, the median differences in DesSevs were 0.02 (Kuopio) and 0.01 (Loewenstein) percentage points. In a second-by-second analysis, ABOSA performed very similarly to Noxturnal and Profusion software in both Kuopio (MCCABOSA = 0.807, MCCNoxturnal = 0.807, MCCProfusion = 0.811) and Loewenstein (MCCABOSA = 0.904, MCCNoxturnal = 0.911, MCCProfusion = 0.871) datasets. Based on Noxturnal and Profusion scorings, the desaturation parameter values were similarly overestimated compared to ABOSA. CONCLUSIONS ABOSA is an accurate and freely available software that calculates both traditional clinical parameters and novel parameters, provides a detailed characterization of desaturation and recovery events, and enables batch analysis of large datasets. These are features that no other software currently provides making ABOSA uniquely suitable for scientific research use.
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Affiliation(s)
- Tuomas Karhu
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland.
| | - Timo Leppänen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland; School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Juha Töyräs
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia; Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Arie Oksenberg
- Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel
| | - Sami Myllymaa
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Sami Nikkonen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland; Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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11
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Smith AN, Abraham J, Shankar R. Oxygen for seizures, more questions than answers: A scoping review. Acta Neurol Scand 2021; 144:719-729. [PMID: 34309004 DOI: 10.1111/ane.13508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ictal hypoxaemia is a feature seen in epileptic seizures, characterized by low oxygen saturations, increasing seizure prolongation risk and possibly contributing to sudden unexpected death in epilepsy (SUDEP). High flow oxygen is recommended in the management of seizures by UK's National Institute of Health and Care excellence (NICE); however, the evidence supporting this recommendation is unclear. AIMS To identify the efficacy of oxygen in the seizure treatment. METHOD A scoping review was conducted using PRISMA-ScR guidance. PsycINFO, EMBASE and MEDLINE were searched along with the references section of identified literature. Articles were critically appraised for study, patient, seizure, oxygen therapy and outcome characteristics, summarized and quality-assessed using Sackett's criteria. RESULTS Literature search identified 623 articles of which five met the pre-criteria for full review. One animal study demonstrated favourable effects of oxygen administration. Three human studies also reported favourable effects of oxygen administration, while one reported outcomes that were not statistically significant. Study design concerns in all identified literature confounded the ability to assess efficacy. All five publications were assigned Sackett's score of 2b. CONCLUSION There is a significant lack of evidence to support the efficacy of oxygen administration in epileptic seizures. Future research is needed.
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Affiliation(s)
| | - Julie Abraham
- Royal Cornwall Hospital Truro University of Exeter Medical School Cornwall UK
| | - Rohit Shankar
- Cornwall Intellectual Disability Epilepsy Research (CIDER) University of Plymouth Medical School Truro UK
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12
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Siahaan YMT, Ketaren RJ, Hartoyo V, Hariyanto TI. Epilepsy and the risk of severe coronavirus disease 2019 outcomes: A systematic review, meta-analysis, and meta-regression. Epilepsy Behav 2021; 125:108437. [PMID: 34839246 PMCID: PMC8590948 DOI: 10.1016/j.yebeh.2021.108437] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/19/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with epilepsy experience seizures, which have been reported to increase and worsen during the coronavirus disease (COVID-19) pandemic. However, the association between epilepsy and COVID-19 outcomes remains unclear. The aim of this study was to analyze whether patients with epilepsy have an increased risk of having poor COVID-19 outcomes. METHODS We comprehensively evaluated potential articles extracted from the medRxiv, Europe PMC, and PubMed databases until June 30, 2021, using selected keywords. All published studies on epilepsy and COVID-19 were selected. We used the Review Manager 5.4 and Comprehensive Meta-Analysis 3 software for statistical analysis. RESULTS Thirteen studies with 67,131 patients with COVID-19 were included in the analysis. Evaluation of the collated data revealed an association between epilepsy and increased severity of COVID-19 (OR, 1.69; 95%CI: 1.11-2.59; p = 0.010; I2 = 29%; random-effect modeling) and mortality from COVID-19 (OR, 1.71; 95%CI: 1.14-2.56; p = 0.010; I2 = 53%; random-effect modeling). The results also showed that the association between epilepsy and increased risk of developing severe COVID-19 is influenced by sex and neurodegenerative disease. CONCLUSIONS The findings of this study suggest that patients with epilepsy are at risk of having poor COVID-19 outcomes. Patients with epilepsy need special attention and should be prioritized for administration of the COVID-19 vaccine. Registration details: PROSPERO (CRD42021264979).
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Affiliation(s)
- Yusak Mangara Tua Siahaan
- Department of Neurology, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang 15811, Indonesia
| | - Retno Jayantri Ketaren
- Department of Neurology, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang 15811, Indonesia
| | - Vinson Hartoyo
- Department of Neurology, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang 15811, Indonesia
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13
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Micalizzi E, Vaudano AE, Giovannini G, Turchi G, Giunta L, Meletti S. Case Report: Ictal Central Apnea as First and Overlooked Symptom in Temporal Lobe Seizures. Front Neurol 2021; 12:753860. [PMID: 34803889 PMCID: PMC8599590 DOI: 10.3389/fneur.2021.753860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/05/2021] [Indexed: 11/23/2022] Open
Abstract
Ictal respiratory changes have been mainly described following generalized tonic-clonic seizures and recently considered to be a biomarker to assess the risk of sudden unexplained death in epilepsy (SUDEP). Nonetheless, modification of respiratory pattern can be related also to focal seizures, especially arising from the temporal lobe. Changes in cardiac function such as tachycardia or bradycardia could be often associated. We report a short case series of four patients with temporal lobe epilepsy admitted to our Epilepsy Monitoring Unit (EMU) presenting with an ictal central apnea as the first clinical manifestation of their seizures. None of these patients was aware of the occurrence of respiratory arrest. Age at onset ranged from 15 to 29 years. One patient had seizures with prolonged central apnea accompanied by a significant decrease in oxygen saturation. Neuroimaging in two patients showed alterations of mesial temporal lobe structures, including the amygdala. Recent neurophysiological studies supported the existence of a cortical network involving the limbic system that modulates downstream brainstem respiratory centers. Monitoring for respiratory changes and oxygen saturation in focal seizures is warranted for their potential value in identifying the epileptogenic zone and for a better understanding of ictal respiratory changes that could potentially define a subgroup of patients with high risk of seizure-related autonomic changes.
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Affiliation(s)
- Elisa Micalizzi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Anna Elisabetta Vaudano
- Neurology Unit, Ospedale Civile di Baggiovara (OCB) Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, Ospedale Civile di Baggiovara (OCB) Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy.,PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Turchi
- Neurology Unit, Ospedale Civile di Baggiovara (OCB) Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Leandra Giunta
- Neurology Unit, Ospedale Civile di Baggiovara (OCB) Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy
| | - Stefano Meletti
- Neurology Unit, Ospedale Civile di Baggiovara (OCB) Hospital, Azienda Ospedaliera-Universitaria, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
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14
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Patodia S, Somani A, Thom M. Review: Neuropathology findings in autonomic brain regions in SUDEP and future research directions. Auton Neurosci 2021; 235:102862. [PMID: 34411885 PMCID: PMC8455454 DOI: 10.1016/j.autneu.2021.102862] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/16/2021] [Accepted: 07/24/2021] [Indexed: 12/21/2022]
Abstract
Autonomic dysfunction is implicated from clinical, neuroimaging and experimental studies in sudden and unexpected death in epilepsy (SUDEP). Neuropathological analysis in SUDEP series enable exploration of acquired, seizure-related cellular adaptations in autonomic and brainstem autonomic centres of relevance to dysfunction in the peri-ictal period. Alterations in SUDEP compared to control groups have been identified in the ventrolateral medulla, amygdala, hippocampus and central autonomic regions. These involve neuropeptidergic, serotonergic and adenosine systems, as well as specific regional astroglial and microglial populations, as potential neuronal modulators, orchestrating autonomic dysfunction. Future research studies need to extend to clinically and genetically characterized epilepsies, to explore if common or distinct pathways of autonomic dysfunction mediate SUDEP. The ultimate objective of SUDEP research is the identification of disease biomarkers for at risk patients, to improve post-mortem recognition and disease categorisation, but ultimately, for exposing potential treatment targets of pharmacologically modifiable and reversible cellular alterations.
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Affiliation(s)
- Smriti Patodia
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Alyma Somani
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Maria Thom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK.
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15
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Czornyj L, Auzmendi J, Lazarowski A. Transporter hypothesis in pharmacoresistant epilepsies Is it at the central or peripheral level? Epilepsia Open 2021; 7 Suppl 1:S34-S46. [PMID: 34542938 PMCID: PMC9340303 DOI: 10.1002/epi4.12537] [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: 04/13/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 12/22/2022] Open
Abstract
The multidrug‐resistance (MDR) phenotype is typically observed in patients with refractory epilepsy (RE) whose seizures are not controlled despite receiving several combinations of more than two antiseizure medications (ASMs) directed against different ion channels or neurotransmitter receptors. Since the use of bromide in 1860, more than 20 ASMs have been developed; however, historically ~30% of cases of RE with MDR phenotype remains unchanged. Irrespective of metabolic biotransformation, the biodistribution of ASMs and their metabolites depends on the functional expression of some ATP‐binding cassette transporters (ABC‐t) in different organs, such as the blood‐brain barrier (BBB), bowel, liver, and kidney, among others. ABC‐t, such as P‐glycoprotein (P‐gp), multidrug resistance–associated protein (MRP‐1), and breast cancer–resistance protein (BCRP), are mainly expressed in excretory organs and play a critical role in the pharmacokinetics (PK) of all drugs. The transporter hypothesis can explain pharmacoresistance to a broad spectrum of ASMs, even when administered simultaneously. Since ABC‐t expression can be induced by hypoxia, inflammation, or seizures, a high frequency of uncontrolled seizures increases the risk of RE. These stimuli can induce ABC‐t expression in excretory organs and in previously non‐expressing (electrically responsive) cells, such as neurons or cardiomyocytes. In this regard, an alternative mechanism to the classical pumping function of P‐gp indicates that P‐gp activity can also produce a significant reduction in resting membrane potential (ΔΨ0 = −60 to −10 mV). P‐gp expression in neurons and cardiomyocytes can produce membrane depolarization and participate in epileptogenesis, heart failure, and sudden unexpected death in epilepsy. On this basis, ABC‐t play a peripheral role in controlling the PK of ASMs and their access to the brain and act at a central level, favoring neuronal depolarization by mechanisms independent of ion channels or neurotransmitters that current ASMs cannot control.
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Affiliation(s)
- Liliana Czornyj
- Neurology Service, "Juan P. Garrahan" National Children's Hospital, Buenos Aires, Argentina
| | - Jerónimo Auzmendi
- Institute for Research in Physiopathology and Clinical Biochemistry (INFIBIOC), Clinical Biochemistry Department, School of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires, Argentina.,National Council for Scientific and Technical Research (CONICET), Buenos Aires, Argentina
| | - Alberto Lazarowski
- Institute for Research in Physiopathology and Clinical Biochemistry (INFIBIOC), Clinical Biochemistry Department, School of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires, Argentina
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16
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Akyüz E, Üner AK, Köklü B, Arulsamy A, Shaikh MF. Cardiorespiratory findings in epilepsy: A recent review on outcomes and pathophysiology. J Neurosci Res 2021; 99:2059-2073. [PMID: 34109651 DOI: 10.1002/jnr.24861] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 12/17/2022]
Abstract
Epilepsy is a debilitating disorder of uncontrollable recurrent seizures that occurs as a result of imbalances in the brain excitatory and inhibitory neuronal signals, that could stem from a range of functional and structural neuronal impairments. Globally, nearly 70 million people are negatively impacted by epilepsy and its comorbidities. One such comorbidity is the effect epilepsy has on the autonomic nervous system (ANS), which plays a role in the control of blood circulation, respiration and gastrointestinal function. These epilepsy-induced impairments in the circulatory and respiratory systems may contribute toward sudden unexpected death in epilepsy (SUDEP). Although, various hypotheses have been proposed regarding the role of epilepsy on ANS, the linking pathological mechanism still remains unclear. Channelopathies and seizure-induced damages in ANS-control brain structures were some of the causal/pathological candidates of cardiorespiratory comorbidities in epilepsy patients, especially in those who were drug resistant. However, emerging preclinical research suggest that neurotransmitter/receptor dysfunction and synaptic changes in the ANS may also contribute to the epilepsy-related autonomic disorders. Thus, pathological mechanisms of cardiorespiratory dysfunction should be elucidated by considering the modifications in anatomy and physiology of the autonomic system caused by seizures. In this regard, we present a comprehensive review of the current literature, both clinical and preclinical animal studies, on the cardiorespiratory findings in epilepsy and elucidate the possible pathological mechanisms of these findings, in hopes to prevent SUDEP especially in patients who are drug resistant.
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Affiliation(s)
- Enes Akyüz
- Department of Biophysics, Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Arda Kaan Üner
- Faculty of Medicine, Yozgat Bozok University, Yozgat, Turkey
| | - Betül Köklü
- Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Alina Arulsamy
- Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Mohd Farooq Shaikh
- Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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17
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Pennell PB, French JA, May RC, Gerard E, Kalayjian L, Penovich P, Gedzelman E, Cavitt J, Hwang S, Pack AM, Sam M, Miller JW, Wilson SH, Brown C, Birnbaum AK, Meador KJ. Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy. N Engl J Med 2020; 383:2547-2556. [PMID: 33369356 PMCID: PMC7919187 DOI: 10.1056/nejmoa2008663] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among women with epilepsy, studies regarding changes in seizure frequency during pregnancy have been limited by the lack of an appropriate nonpregnant comparator group to provide data on the natural course of seizure frequency in both groups. METHODS In this prospective, observational, multicenter cohort study, we compared the frequency of seizures during pregnancy through the peripartum period (the first 6 weeks after birth) (epoch 1) with the frequency during the postpartum period (the following 7.5 months after pregnancy) (epoch 2). Nonpregnant women with epilepsy were enrolled as controls and had similar follow-up during an 18-month period. The primary outcome was the percentage of women who had a higher frequency of seizures that impaired awareness during epoch 1 than during epoch 2. We also compared changes in the doses of antiepileptic drugs that were administered in the two groups during the first 9 months of epoch 1. RESULTS We enrolled 351 pregnant women and 109 controls with epilepsy. Among the 299 pregnant women and 93 controls who had a history of seizures that impaired awareness and who had available data for the two epochs, seizure frequency was higher during epoch 1 than during epoch 2 in 70 pregnant women (23%) and in 23 controls (25%) (odds ratio, 0.93; 95% confidence interval [CI], 0.54 to 1.60). During pregnancy, the dose of an antiepileptic drug was changed at least once in 74% of pregnant women and in 31% of controls (odds ratio, 6.36; 95% CI, 3.82 to 10.59). CONCLUSIONS Among women with epilepsy, the percentage who had a higher incidence of seizures during pregnancy than during the postpartum period was similar to that in women who were not pregnant during the corresponding epochs. Changes in doses of antiepileptic drugs occurred more frequently in pregnant women than in nonpregnant women during similar time periods. (Funded by the National Institutes of Health; MONEAD ClinicalTrials.gov number, NCT01730170.).
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Affiliation(s)
- Page B Pennell
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jacqueline A French
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Ryan C May
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Elizabeth Gerard
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Laura Kalayjian
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Patricia Penovich
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Evan Gedzelman
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Jennifer Cavitt
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Sean Hwang
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Alison M Pack
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Maria Sam
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - John W Miller
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Steffanie H Wilson
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Carrie Brown
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Angela K Birnbaum
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
| | - Kimford J Meador
- From Brigham and Women's Hospital, Harvard Medical School, Boston (P.B.P.); New York University Comprehensive Epilepsy Center (J.A.F.) and Columbia University (A.M.P.), New York, and Northwell Health, Great Neck (S.H.) - both in New York; Emmes, Rockville, MD (R.C.M., S.H.W., C.B.); Northwestern University, Chicago (E. Gerard); the University of Southern California, Los Angeles (L.K.), and Stanford University, Palo Alto (K.J.M.) - both in California; the Minnesota Epilepsy Group, St. Paul (P.P.), and the University of Minnesota, Minneapolis (A.K.B.); Emory University School of Medicine, Atlanta (E. Gedzelman); the University of Cincinnati, Cincinnati (J.C.); Wake Forest University, Winston-Salem, NC (M.S.); and the University of Washington, Seattle (J.W.M.)
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18
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Patodia S, Tan I, Ellis M, Somani A, Scheffer IE, Sisodiya SM, Thom M. Medullary tyrosine hydroxylase catecholaminergic neuronal populations in sudden unexpected death in epilepsy. Brain Pathol 2020; 31:133-143. [PMID: 32852867 PMCID: PMC8018054 DOI: 10.1111/bpa.12891] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/12/2020] [Accepted: 08/06/2020] [Indexed: 12/26/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is mechanistically complex and one probable cause is seizure‐related respiratory dysfunction. Medullary respiratory regulatory nuclei include the pre‐Bötzinger complex (pre‐BötC) in the ventrolateral medulla (VLM), the medullary raphé nuclei (MR) and nucleus of solitary tract in the dorsomedial medulla (DMM). The region of the VLM also contains intermingled tyrosine hydroxylase (TH) catecholaminergic neurones which directly project to the pre‐BötC and regulate breathing under hypoxic conditions and our aim was to evaluate these neurones in SUDEP cases. In post‐mortem cases from three groups [SUDEP (18), epilepsy controls (8) and non‐epilepsy controls (16)] serial sections of medulla (obex + 2 to + 13 mm) were immunolabeled for TH. Three regions of interest (ROI) were outlined (VLM, DMM and MR) and TH‐immunoreactive (TH‐IR) neurones were evaluated using automated detection for overall labeling index (neurones and processes) and neuronal densities and compared between groups and relative to obex level. C‐fos immunoreactivity was also semi‐quantitatively evaluated in these regions. We found no significant difference in the density of TH‐IR neurones or labeling index between the groups in all regions. Significantly more TH‐IR neurones were present in the DMM region than VLM in non‐epilepsy cases only (P < 0.01). Regional variations in TH‐IR neurones with obex level were seen in all groups except SUDEP. We also identified occasional TH neurones in the MR region in all groups. There was significantly less c‐fos labeling in the VLM and MR in SUDEP than non‐epilepsy controls but no difference with epilepsy controls. In conclusion, in this series we found no evidence for alteration of total medullary TH‐IR neuronal numbers in SUDEP but noted some differences in their relative distribution in the medulla and c‐fos neurones compared to control groups which may be relevant to the mechanism of death.
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Affiliation(s)
- Smriti Patodia
- Department of Clinical and Experimental epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 2BG, UK
| | - Ian Tan
- Department of Clinical and Experimental epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 2BG, UK
| | - Matthew Ellis
- School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Alyma Somani
- Department of Clinical and Experimental epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 2BG, UK
| | - Ingrid E Scheffer
- Epilepsy Research Centre, Department of Medicine (Neurology), University of Melbourne, Victoria, 3052, Australia
| | - Sanjay M Sisodiya
- Department of Clinical and Experimental epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 2BG, UK.,Chalfont Centre for Epilepsy, Bucks, SL9 0RJ, UK
| | - Maria Thom
- Department of Clinical and Experimental epilepsy, UCL Queen Square Institute of Neurology, London, WC1N 2BG, UK.,School of Cancer Sciences, University of Southampton, Southampton, UK
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19
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Patodia S, Tachrount M, Somani A, Scheffer I, Yousry T, Golay X, Sisodiya SM, Thom M. MRI and pathology correlations in the medulla in sudden unexpected death in epilepsy (SUDEP): a postmortem study. Neuropathol Appl Neurobiol 2020; 47:157-170. [PMID: 32559314 DOI: 10.1111/nan.12638] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/10/2020] [Indexed: 12/21/2022]
Abstract
AIMS Sudden unexpected death in epilepsy (SUDEP) likely arises as a result of autonomic dysfunction around the time of a seizure. In vivo MRI studies report volume reduction in the medulla and other brainstem autonomic regions. Our aim, in a pathology series, is to correlate regional quantitative features on 9.4T MRI with pathology measures in medullary regions. METHODS Forty-seven medullae from 18 SUDEP, 18 nonepilepsy controls and 11 epilepsy controls were studied. In 16 cases, representing all three groups, ex vivo 9.4T MRI of the brainstem was carried out. Five regions of interest (ROI) were delineated, including the reticular formation zone (RtZ), and actual and relative volumes (RV), as well as T1, T2, T2* and magnetization transfer ratio (MTR) measurements were evaluated on MRI. On serial sections, actual and RV estimates using Cavalieri stereological method and immunolabelling indices for myelin basic protein, synaptophysin and Microtubule associated protein 2 (MAP2) were carried out in similar ROI. RESULTS Lower relative RtZ volumes in the rostral medulla but higher actual volumes in the caudal medulla were observed in SUDEP (P < 0.05). No differences between groups for T1, T2, T2* and MTR values in any region was seen but a positive correlation between T1 values and MAP2 labelling index in RtZ (P < 0.05). Significantly lower MAP2 LI were noted in the rostral medulla RtZ in epilepsy cases (P < 0.05). CONCLUSIONS Rostro-caudal alterations of medullary volume in SUDEP localize with regions containing respiratory regulatory nuclei. They may represent seizure-related alterations, relevant to the pathophysiology of SUDEP.
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Affiliation(s)
- S Patodia
- Department of Neuropathology, UCL Queen Square Institute of Neurology, London, UK.,Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - M Tachrount
- Neuroradiology Academic Unit, Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK.,FMRIB, Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - A Somani
- Department of Neuropathology, UCL Queen Square Institute of Neurology, London, UK.,Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - I Scheffer
- Department of Medicine (Neurology), Epilepsy Research Centre, University of Melbourne, Melbourne, VIC, Australia
| | - T Yousry
- Neuroradiology Academic Unit, Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - X Golay
- Neuroradiology Academic Unit, Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - S M Sisodiya
- Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - M Thom
- Department of Neuropathology, UCL Queen Square Institute of Neurology, London, UK.,Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
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20
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Park K, Kanth K, Bajwa S, Girgis F, Shahlaie K, Seyal M. Seizure-related apneas have an inconsistent linkage to amygdala seizure spread. Epilepsia 2020; 61:1253-1260. [PMID: 32391925 DOI: 10.1111/epi.16518] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/31/2020] [Accepted: 04/08/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is a frequent cause of death in epilepsy. Respiratory dysfunction is implicated as a critical factor in SUDEP pathophysiology. Human studies have shown that electrical stimulation of the amygdala resulted in apnea, indicating that the amygdala has a role in respiration control. Unilateral amygdala stimulation resulted in immediate onset of respiratory dysfunction occurring only during nose breathing. In small numbers of patients, some but not all spontaneous seizures resulted in apnea occurring shortly after seizure spread to the amygdala. With this study we aimed to determine whether seizure onset or spread to the amygdala was necessary and sufficient to cause apnea. METHODS We investigated the temporal relationship between apnea/hypopnea (AH) onset and initial seizure involvement within the amygdala in patients with implanted depth electrodes. RESULTS Data from 17 patients (11 female) with 47 seizures were analyzed. With seven seizures (three patients), AH preceded amygdala seizure involvement by 2 to 55 seconds. There was no AH with four seizures (three patients) that involved the amygdala. With eight seizures (four patients) AH occurred within 2 seconds following amygdala seizure onset. With 28 seizures, AH started >2 seconds after amygdala seizure onset (range 3-158 seconds). Following seizure onset, there was a significant difference between AH onset time and amygdala seizure onset (P < .001). The mean ± standard deviation (SD) AH onset was 27.8 ± 41.06 seconds, and the mean time to amygdala involvement was 8.83 ± 20.19 seconds. SIGNIFICANCE There is a wide range of AH onset times relative to amygdala seizure involvement. With some seizures, amygdala seizure involvement occurs without AH. With other seizures, AH precedes amygdala seizures, suggesting that, with spontaneous seizures, involvement of the amygdala may not be crucial to induction of AH with all seizures. Other pathophysiology impacting brainstem respiratory networks may be of greater relevance to seizure-triggered apneas.
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Affiliation(s)
- Katherine Park
- Department of Neurology, University of California, Davis, California
| | - Kiran Kanth
- Department of Neurology, University of California, Davis, California
| | - Sami Bajwa
- Department of Neurology, University of California, Davis, California
| | - Fady Girgis
- Department of Neurological Surgery, University of California, Davis, California
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, Davis, California
| | - Masud Seyal
- Department of Neurology, University of California, Davis, California
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21
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Simblett SK, Biondi A, Bruno E, Ballard D, Stoneman A, Lees S, Richardson MP, Wykes T. Patients' experience of wearing multimodal sensor devices intended to detect epileptic seizures: A qualitative analysis. Epilepsy Behav 2020; 102:106717. [PMID: 31785481 DOI: 10.1016/j.yebeh.2019.106717] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The health management of patients with epilepsy could be improved by wearing devices that reliably detect when epileptic seizures happen. For the devices to be widely adopted, they must be acceptable and easy to use for patients, and their views are very important. Previous studies have collected feedback from patients on hypothetical devices, but very few have examined experience of wearing actual devices. PURPOSE This study assessed the first-hand experiences of people with epilepsy using wearable devices, continuously over a period of time. The aim was to understand how acceptable and easy they were to use, and whether it is reasonable to expect that people will use them. MATERIALS AND METHODS Adults with a diagnosis of epilepsy admitted routinely to a hospital epilepsy monitoring unit were asked to wear one, or more, wearable biosensor devices, tested for seizure detection. The devices are designed to continuously monitor and record signals from the body (biosignals). Participants completed semistructured interviews about their experiences of wearing the device(s). A systematic thematic analysis extracted themes from the interviews, focusing on acceptability and usability. Feedback was organized into (1) participants' experiences of the devices, any support they required and reasons for stopping wearing them; (2) their thoughts about using this technology outside a hospital setting. RESULTS Twenty-one people with epilepsy wore one, or more, wearable devices for an average of 112.81 (SD = 71.83) hours. Participants found the devices convenient, and had no problem wearing them in hospital or sharing the data collected from them with the researchers and medical professionals. However, the presence of wires, bulky size, discomfort, and need for support, moderated experience. Participants' thoughts about wearing them in everyday life were strongly influenced by how visible and perceived accuracy. Willingness to use a smartphone app to complete questionnaires depended on the frequency, number of questions, and support. CONCLUSIONS Overall, this work provides evidence about the feasibility and acceptability of using wearable devices to monitor seizure activity in people with epilepsy. Key barriers and facilitators to use while in hospital and hypothetical use in everyday life were identified and will be helpful for guiding future implementation.
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Affiliation(s)
- Sara Katherine Simblett
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, United Kingdom.
| | - Andrea Biondi
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), London, United Kingdom
| | - Elisa Bruno
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), London, United Kingdom
| | - Dominic Ballard
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), London, United Kingdom
| | - Amanda Stoneman
- Epilepsy Action (British Epilepsy Association), New Anstey House, Leeds, United Kingdom; RADAR-CNS Patient Advisory Board, King's College London, London, United Kingdom
| | - Simon Lees
- RADAR-CNS Patient Advisory Board, King's College London, London, United Kingdom
| | - Mark P Richardson
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, London, United Kingdom
| | - Til Wykes
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, United Kingdom; NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust, King's College London, London, United Kingdom
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22
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Vega JL, Emmady P, Roels C, Conforti J, Ramirez C, Dorak MT. The Magnitude of Postconvulsive Leukocytosis Mirrors the Severity of Periconvulsive Respiratory Compromise: A Single Center Retrospective Study. Front Neurol 2019; 10:1291. [PMID: 31866936 PMCID: PMC6910016 DOI: 10.3389/fneur.2019.01291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/22/2019] [Indexed: 11/21/2022] Open
Abstract
Background: Generalized epileptic convulsions frequently exhibit transient respiratory symptoms and non-infectious leukocytosis. While these peri-ictal effects appear to arise independently from one another, the possibility that they stem from a common ictal pathophysiological response has yet to be explored. We aimed to investigate whether peri-ictal respiratory symptoms and postictal leukocytosis coexist. Methods: We performed a single center retrospective chart review of 446 patients brought to our emergency department between January 1, 2017 and August 23, 2018 for the care of generalized epileptic convulsions with or without status epilepticus. We included 152 patients who were stratified based on the presence (PeCRC+) or absence (PeCRC–) of overt periconvulsive respiratory compromise (PeCRC). In addition, patients were stratified based on the presence or absence of postconvulsive leukocytosis (PoCL), defined as an initial postconvulsive white blood cell (WBC) count ≥ 11,000 cells/mm3. Triage vital signs, and chest x ray (CXR) abnormalities were also examined. Results: Overt PeCRC was observed in 31.6% of patients, 43% of whom required emergent endotracheal intubations. PoCL was observed in 37.5% of patients, and was more likely to occur in PeCRC+ than in PeCRC– patients (79.2 vs. 18.2%; OR = 17.0; 95% CI = 7.2–40.9; p < 0.001). Notably, the magnitude of PoCL was proportional to the severity of PeCRC, as the postconvulsive WBC count demonstrated a negative correlation with triage hemoglobin oxygen saturation (R = −0.22; p < 0.01; CI = −0.48 to −0.07). Moreover, a receiver operating characteristic analysis of the WBC count's performance as predictor of endotracheal intubation reached a significant area under the curve value of 0.81 (95% CI = 0.71–0.90; p < 0.001). Finally, PeCRC+ patients demonstrated frequent CXR abnormalities, and their postconvulsive WBC counts correlated directly with triage heart rate (R = 0.53; p < 0.001). Conclusion: Our data support the existence of an ictal pathophysiological response, which induces proportional degrees of PoCL and PeCRC. We suggest this response is at least partially propelled by systemic catecholamines.
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Affiliation(s)
- Jose L Vega
- Department of Neurosciences and Stroke, Novant Health, Forsyth Medical Center, Winston-Salem, NC, United States.,TeleNeurologia SAS, Medellin, Colombia
| | - Prabhu Emmady
- Department of Neurosciences and Stroke, Novant Health, Forsyth Medical Center, Winston-Salem, NC, United States
| | - Christina Roels
- Department of Neurosciences and Stroke, Novant Health, Forsyth Medical Center, Winston-Salem, NC, United States
| | - John Conforti
- Department of Critical Care, Novant Health, Forsyth Medical Center, Winston-Salem, NC, United States
| | | | - Mehmet T Dorak
- School of Life Sciences, Pharmacy & Chemistry, Kingston University London, United Kingdom
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23
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Apnea Associated with Brainstem Seizures in Cacna1a S218L Mice Is Caused by Medullary Spreading Depolarization. J Neurosci 2019; 39:9633-9644. [PMID: 31628185 DOI: 10.1523/jneurosci.1713-19.2019] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/17/2019] [Accepted: 10/10/2019] [Indexed: 01/08/2023] Open
Abstract
Seizure-related apnea is common and can be lethal. Its mechanisms however remain unclear and preventive strategies are lacking. We postulate that brainstem spreading depolarization (SD), previously associated with lethal seizures in animal models, initiates apnea upon invasion of brainstem respiratory centers. To study this, we assessed effects of brainstem seizures on brainstem function and respiration in male and female mice carrying a homozygous S218L missense mutation that leads to gain-of-function of voltage-gated CaV2.1 Ca2+ channels and high risk for fatal seizures. Recordings of brainstem DC potential and neuronal activity, cardiorespiratory activity and local tissue oxygen were performed in freely behaving animals. Brainstem SD occurred during all spontaneous fatal seizures and, unexpectedly, during a subset of nonfatal seizures. Seizure-related SDs in the ventrolateral medulla correlated with respiratory suppression. Seizures induced by stimulation of the inferior colliculus could evoke SD that spread in a rostrocaudal direction, preceding local tissue hypoxia and apnea, indicating that invasion of SD into medullary respiratory centers initiated apnea and hypoxia rather than vice versa Fatal outcome was prevented by timely resuscitation. Moreover, NMDA receptor antagonists MK-801 and memantine prevented seizure-related SD and apnea, which supports brainstem SD as a prerequisite for brainstem seizure-related apnea in this animal model and has translational value for developing strategies that prevent fatal ictal apnea.SIGNIFICANCE STATEMENT Apnea during and following seizures is common, but also likely implicated in sudden unexpected death in epilepsy (SUDEP). This underlines the need to understand mechanisms for potentially lethal seizure-related apnea. In the present work we show, in freely behaving SUDEP-prone transgenic mice, that apnea is induced when spontaneous brainstem seizure-related spreading depolarization (SD) reaches respiratory nuclei in the ventrolateral medulla. We show that brainstem seizure-related medullary SD is followed by local hypoxia and recovers during nonfatal seizures, but not during fatal events. NMDA receptor antagonists prevented medullary SD and apnea, which may be of translational value.
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