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Bosch AT, Sander JW, Thijs RD. Antiseizure Medications and Sudden Unexpected Death in Epilepsy: An Updated Review. CNS Drugs 2024; 38:807-817. [PMID: 39112912 PMCID: PMC11377662 DOI: 10.1007/s40263-024-01112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 09/06/2024]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is responsible for most epilepsy-related deaths. It is mainly related to unwitnessed nocturnal convulsions, either focal to bilateral or generalised tonic-clonic seizures (TCS). Targeted preventive strategies are currently lacking as underlying mechanisms are largely unknown. Antiseizure medications (ASMs) modulate SUDEP risk through seizure reduction, but it is yet undetermined whether individual ASMs or other medications could also influence the internal SUDEP cascade. Seizure detection devices (SDD) may offer an alternative strategy by preventing TCS from being unwitnessed. Here, we critically evaluated the current evidence on the influence of ASMs, non-epilepsy concomitant drugs and SDD on SUDEP occurrence. We found no robust evidence for the effect of starting ASMs on SUDEP beyond TCS control, but we found some indications of a protective effect for polytherapy. We found no signs that specific ASMs exert a risk for SUDEP. One study suggested a possible protective effect of levetiracetam requiring further investigation. Only a few small studies addressed the association between non-epilepsy concomitant drugs and SUDEP, with no consistent effect for psychotropic medications and one more extensive study suggesting a lower risk among statin users. We only found indirect evidence indicating a protective effect for enhancing nocturnal supervision without explicitly addressing the impact of SDD on SUDEP occurrence. Further work is needed to explore the potential of ASMs and other interventions to modulate SUDEP risk, and they should accurately account for TCS frequency, polypharmacy and markers of non-adherence.
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Affiliation(s)
- Anemoon T Bosch
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, SL9 0RJ, UK
- Neurology Department, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW, Heemstede, The Netherlands.
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands.
- UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK.
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Leitner D, Pires G, Kavanagh T, Kanshin E, Askenazi M, Ueberheide B, Devinsky O, Wisniewski T, Drummond E. Similar brain proteomic signatures in Alzheimer's disease and epilepsy. Acta Neuropathol 2024; 147:27. [PMID: 38289539 PMCID: PMC10827928 DOI: 10.1007/s00401-024-02683-4] [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: 10/04/2023] [Revised: 12/15/2023] [Accepted: 01/03/2024] [Indexed: 02/01/2024]
Abstract
The prevalence of epilepsy is increased among Alzheimer's Disease (AD) patients and cognitive impairment is common among people with epilepsy. Epilepsy and AD are linked but the shared pathophysiological changes remain poorly defined. We aim to identify protein differences associated with epilepsy and AD using published proteomics datasets. We observed a highly significant overlap in protein differences in epilepsy and AD: 89% (689/777) of proteins altered in the hippocampus of epilepsy patients were significantly altered in advanced AD. Of the proteins altered in both epilepsy and AD, 340 were altered in the same direction, while 216 proteins were altered in the opposite direction. Synapse and mitochondrial proteins were markedly decreased in epilepsy and AD, suggesting common disease mechanisms. In contrast, ribosome proteins were increased in epilepsy but decreased in AD. Notably, many of the proteins altered in epilepsy interact with tau or are regulated by tau expression. This suggests that tau likely mediates common protein changes in epilepsy and AD. Immunohistochemistry for Aβ and multiple phosphorylated tau species (pTau396/404, pTau217, pTau231) showed a trend for increased intraneuronal pTau217 and pTau231 but no phosphorylated tau aggregates or amyloid plaques in epilepsy hippocampal sections. Our results provide insights into common mechanisms in epilepsy and AD and highlights the potential role of tau in mediating common pathological protein changes in epilepsy and AD.
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Affiliation(s)
- Dominique Leitner
- Center for Cognitive Neurology, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, 10016, USA
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, 10016, USA
| | - Geoffrey Pires
- Center for Cognitive Neurology, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, 10016, USA
| | - Tomas Kavanagh
- Brain and Mind Centre and School of Medical Sciences, University of Sydney, Camperdown, NSW, 2050, Australia
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies and Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, 10016, USA
| | | | - Beatrix Ueberheide
- Center for Cognitive Neurology, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, 10016, USA
- Proteomics Laboratory, Division of Advanced Research Technologies and Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, 10016, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, 10016, USA
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, 10016, USA.
| | - Eleanor Drummond
- Center for Cognitive Neurology, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, 10016, USA.
- Brain and Mind Centre and School of Medical Sciences, University of Sydney, Camperdown, NSW, 2050, Australia.
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3
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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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4
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Leitner DF, Siu Y, Korman A, Lin Z, Kanshin E, Friedman D, Devore S, Ueberheide B, Tsirigos A, Jones DR, Wisniewski T, Devinsky O. Metabolomic, proteomic, and transcriptomic changes in adults with epilepsy on modified Atkins diet. Epilepsia 2023; 64:1046-1060. [PMID: 36775798 PMCID: PMC10372873 DOI: 10.1111/epi.17540] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE High-fat and low-carbohydrate diets can reduce seizure frequency in some treatment-resistant epilepsy patients, including the more flexible modified Atkins diet (MAD), which is more palatable, mimicking fasting and inducing high ketone body levels. Low-carbohydrate diets may shift brain energy production, particularly impacting neuron- and astrocyte-linked metabolism. METHODS We evaluated the effect of short-term MAD on molecular mechanisms in adult epilepsy patients from surgical brain tissue and plasma compared to control participants consuming a nonmodified higher carbohydrate diet (n = 6 MAD, mean age = 43.7 years, range = 21-53, diet for average 10 days; n = 10 control, mean age = 41.9 years, range = 28-64). RESULTS By metabolomics, there were 13 increased metabolites in plasma (n = 15 participants with available specimens), which included 4.10-fold increased ketone body 3-hydroxybutyric acid, decreased palmitic acid in cortex (n = 16), and 11 decreased metabolites in hippocampus (n = 6), which had top associations with mitochondrial functions. Cortex and plasma 3-hydroxybutyric acid levels had a positive correlation (p = .0088, R2 = .48). Brain proteomics and RNAseq identified few differences, including 2.75-fold increased hippocampal MT-ND3 and trends (p < .01, false discovery rate > 5%) in hippocampal nicotinamide adenine dinucleotide (NADH)-related signaling pathways (activated oxidative phosphorylation and inhibited sirtuin signaling). SIGNIFICANCE Short-term MAD was associated with metabolic differences in plasma and resected epilepsy brain tissue when compared to control participants, in combination with trending expression changes observed in hippocampal NADH-related signaling pathways. Future studies should evaluate how brain molecular mechanisms are altered with long-term MAD in a larger cohort of epilepsy patients, with correlations to seizure frequency, epilepsy syndrome, and other clinical variables. [Clinicaltrials.gov NCT02565966.].
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Affiliation(s)
- Dominique F. Leitner
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, United States of America
- Center for Cognitive Neurology, Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Yik Siu
- Metabolomics Core Resource Laboratory, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Aryeh Korman
- Metabolomics Core Resource Laboratory, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Ziyan Lin
- Applied Bioinformatics Laboratories, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Daniel Friedman
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Sasha Devore
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Beatrix Ueberheide
- Center for Cognitive Neurology, Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
- Proteomics Laboratory, Division of Advanced Research Technologies, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Aristotelis Tsirigos
- Applied Bioinformatics Laboratories, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Pathology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Drew R. Jones
- Metabolomics Core Resource Laboratory, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Pathology, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, United States of America
- Department of Neurology, New York University Grossman School of Medicine, New York, New York, United States of America
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5
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Yan F, Zhang F, Yan Y, Zhang L, Chen Y. Sudden unexpected death in epilepsy: Investigation of autopsy-based studies. Front Neurol 2023; 14:1126652. [PMID: 36873450 PMCID: PMC9978181 DOI: 10.3389/fneur.2023.1126652] [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: 12/18/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023] Open
Abstract
Epilepsy is a common neurological disorder that is associated with increased morbidity and mortality. Sudden unexpected death in epilepsy (SUDEP) is one of the most common causes for epilepsy-related deaths and its characteristics remain largely unknown, particularly from a forensic autopsy perspective. The present study aimed to investigate the neurological, cardiac, and pulmonary findings for a total of 388 SUDEP decedents, encompassing three cases from our forensic center during 2011-2020 and 385 literature-reported autopsy cases. In the cases mentioned in this study, two of them presented with only mild cardiac abnormalities, such as focal myocarditis and mild coronary atherosclerosis of the left anterior coronary artery. The third one was negative of any pathological findings. After pooling together these SUDEP cases, we found that neurological changes (n = 218 cases, 56.2%) were the most common postmortem findings associated with SUDEP, with cerebral edema/congestion (n = 60 cases, 15.5%) and old traumatic brain injury (n = 58 cases, 14.9%) being the major findings. Interstitial fibrosis, myocyte disarray/hypertrophy, and mild coronary artery atherosclerosis were the most common findings related to primary cardiac pathology, documented in 49 (12.6%), 18 (4.6%), and 15 (3.9%) cases, respectively. Non-specific pulmonary edema was the major finding in the lungs. This is an autopsy-based study that reports the scenario of postmortem findings for SUDEP cases. Our study paves the way for understanding the pathogenesis of SUDEP and the interpretation of death.
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Affiliation(s)
- Fengping Yan
- Department of Forensic Medicine, School of Basic Medical Sciences, Gannan Medical University, Ganzhou, Jiangxi, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Disease of Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Fu Zhang
- Key Laboratory of Forensic Pathology, Ministry of Public Security and Criminal Technology Center of Guangdong Province Public Security Bureau, Guangzhou, Guangdong, China
| | - Yanan Yan
- Department of Forensic Medicine, School of Basic Medical Sciences, Gannan Medical University, Ganzhou, Jiangxi, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Disease of Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Le Zhang
- Forensic Center of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Yuanyuan Chen
- Department of Forensic Medicine, School of Basic Medical Sciences, Gannan Medical University, Ganzhou, Jiangxi, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Disease of Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
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6
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Zhang Q, Suller-Marti A, Ding JJ, Deng G, He W, Burneo JG, Hammond RR, Ang LC. Epilepsy-associated death in the Southwestern Ontario: A clinicopathological correlation study. Brain Pathol 2022; 33:e13121. [PMID: 36180818 PMCID: PMC10041075 DOI: 10.1111/bpa.13121] [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: 04/24/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022] Open
Abstract
Patients with epilepsy are at elevated risk for premature mortality, of which sudden unexpected death in epilepsy (SUDEP) is one of the leading causes. SUDEP incidence varies significantly depending on the population and the methods used to document the cause of death. We performed retrospective case review at the London Health Sciences Centre for the period of 2000 to 2018. Clinical information, scene investigations, general pathology findings, toxicology, and neuropathology findings were obtained, examined, and confirmed by two neuropathologists and one epileptologist. The characteristics were compared and summarized. We also evaluated the impact of 2010 revision of Ontario Coroner Act Regulation, which significantly limited whole brain examination. Among the 12,206 cases reviewed, we identified 152 cases with a known history of epilepsy. Ninety-seven cases (64%) were classified as SUDEP. There were significantly more SUDEP decedents found dead unwitnessed at night in prone position, than non-SUDEP. Generalized seizures were strongly associated with SUDEP. A male predominance was observed in SUDEP group between 15 and 35 years old. Near half of the brains examined were "unremarkable." There was no difference in neuropathology findings between SUDEP and non-SUDEP groups. After implementation of the 2010 revision of Ontario Coroner Act Regulation, fixed whole brain examination was reduced from 88% to 7% of the epilepsy-related death investigation. Except a lower diagnosis rate of "inflammatory/infectious changes," there were no significant differences in neuropathology findings. This is the first detailed clinical-pathological study on epilepsy-related death based on a Canadian cohort. This study reinforces the previously reported findings in SUDEP and highlights the importance of clinicopathological correlation for accurate classification of epilepsy-related death.
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Affiliation(s)
- Qi Zhang
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ana Suller-Marti
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jane Jian Ding
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gansen Deng
- Department of Statistical and Actuarial Sciences, Western University, London, Ontario, Canada
| | - Wenqing He
- Department of Statistical and Actuarial Sciences, Western University, London, Ontario, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Neuroepidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert R Hammond
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lee-Cyn Ang
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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7
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Leitner DF, Kanshin E, Askenazi M, Faustin A, Friedman D, Devore S, Ueberheide B, Wisniewski T, Devinsky O. Raphe and ventrolateral medulla proteomics in epilepsy and sudden unexpected death in epilepsy. Brain Commun 2022; 4:fcac186. [PMID: 35928051 PMCID: PMC9344977 DOI: 10.1093/braincomms/fcac186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/29/2022] [Accepted: 07/11/2022] [Indexed: 12/26/2022] Open
Abstract
Brainstem nuclei dysfunction is implicated in sudden unexpected death in epilepsy. In animal models, deficient serotonergic activity is associated with seizure-induced respiratory arrest. In humans, glia are decreased in the ventrolateral medullary pre-Botzinger complex that modulate respiratory rhythm, as well as in the medial medullary raphe that modulate respiration and arousal. Finally, sudden unexpected death in epilepsy cases have decreased midbrain volume. To understand the potential role of brainstem nuclei in sudden unexpected death in epilepsy, we evaluated molecular signalling pathways using localized proteomics in microdissected midbrain dorsal raphe and medial medullary raphe serotonergic nuclei, as well as the ventrolateral medulla in brain tissue from epilepsy patients who died of sudden unexpected death in epilepsy and other causes in diverse epilepsy syndromes and non-epilepsy control cases (n = 15-16 cases per group/region). Compared with the dorsal raphe of non-epilepsy controls, we identified 89 proteins in non-sudden unexpected death in epilepsy and 219 proteins in sudden unexpected death in epilepsy that were differentially expressed. These proteins were associated with inhibition of EIF2 signalling (P-value of overlap = 1.29 × 10-8, z = -2.00) in non-sudden unexpected death in epilepsy. In sudden unexpected death in epilepsy, there were 10 activated pathways (top pathway: gluconeogenesis I, P-value of overlap = 3.02 × 10-6, z = 2.24) and 1 inhibited pathway (fatty acid beta-oxidation, P-value of overlap = 2.69 × 10-4, z = -2.00). Comparing sudden unexpected death in epilepsy and non-sudden unexpected death in epilepsy, 10 proteins were differentially expressed, but there were no associated signalling pathways. In both medullary regions, few proteins showed significant differences in pairwise comparisons. We identified altered proteins in the raphe and ventrolateral medulla of epilepsy patients, including some differentially expressed in sudden unexpected death in epilepsy cases. Altered signalling pathways in the dorsal raphe of sudden unexpected death in epilepsy indicate a shift in cellular energy production and activation of G-protein signalling, inflammatory response, stress response and neuronal migration/outgrowth. Future studies should assess the brain proteome in relation to additional clinical variables (e.g. recent tonic-clonic seizures) and in more of the reciprocally connected cortical and subcortical regions to better understand the pathophysiology of epilepsy and sudden unexpected death in epilepsy.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, Grossman
School of Medicine, New York University, 223 East 34th
Street, New York, NY 10016, USA
| | - Manor Askenazi
- Biomedical Hosting LLC, Arlington, MA
02140, USA
- Department of Biochemistry and Molecular Pharmacology, Grossman School of
Medicine, New York University, 223 East 34th Street, New
York, NY 10016, USA
| | - Arline Faustin
- Center for Cognitive Neurology, Department of Neurology, Grossman School of
Medicine, New York University, 223 East 34th Street, New
York, NY 10016, USA
- Department of Pathology, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
| | - Beatrix Ueberheide
- Proteomics Laboratory, Division of Advanced Research Technologies, Grossman
School of Medicine, New York University, 223 East 34th
Street, New York, NY 10016, USA
- Department of Biochemistry and Molecular Pharmacology, Grossman School of
Medicine, New York University, 223 East 34th Street, New
York, NY 10016, USA
- Center for Cognitive Neurology, Department of Neurology, Grossman School of
Medicine, New York University, 223 East 34th Street, New
York, NY 10016, USA
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, Grossman School of
Medicine, New York University, 223 East 34th Street, New
York, NY 10016, USA
- Department of Pathology, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
- Department of Psychiatry, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, Grossman School of Medicine, New York
University, 223 East 34th Street, New York, NY
10016, USA
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8
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Leitner DF, Kanshin E, Askenazi M, Siu Y, Friedman D, Devore S, Jones D, Ueberheide B, Wisniewski T, Devinsky O. Pilot study evaluating everolimus molecular mechanisms in tuberous sclerosis complex and focal cortical dysplasia. PLoS One 2022; 17:e0268597. [PMID: 35587487 PMCID: PMC9119437 DOI: 10.1371/journal.pone.0268597] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/02/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) and some focal cortical dysplasias (FCDs) are associated with dysfunctional mTOR signaling, resulting in increased cell growth and ribosomal S6 protein phosphorylation (phospho-S6). mTOR inhibitors can reduce TSC tumor growth and seizure frequency, and preclinical FCD studies indicate seizure suppression. This pilot study evaluated safety of mTOR inhibitor everolimus in treatment resistant (failure of >2 anti-seizure medications) TSC and FCD patients undergoing surgical resection and to assess mTOR signaling and molecular pathways. METHODS AND FINDINGS We evaluated everolimus in 14 treatment resistant epilepsy patients undergoing surgical resection (4.5 mg/m2 daily for 7 days; n = 4 Active, mean age 18.3 years, range 4-26; n = 10, Control, mean age 13.1, range 3-45). Everolimus was well tolerated. Mean plasma everolimus in Active participants were in target range (12.4 ng/ml). Brain phospho-S6 was similar in Active and Control participants with a lower trend in Active participants, with Ser235/236 1.19-fold (p = 0.67) and Ser240/244 1.15-fold lower (p = 0.66). Histologically, Ser235/236 was 1.56-fold (p = 0.37) and Ser240/244 was 5.55-fold lower (p = 0.22). Brain proteomics identified 11 proteins at <15% false discovery rate associated with coagulation system (p = 1.45x10-9) and acute phase response (p = 1.23x10-6) activation. A weighted gene correlation network analysis (WGCNA) of brain proteomics and phospho-S6 identified 5 significant modules. Higher phospho-S6 correlated negatively with cellular respiration and synaptic transmission and positively with organophosphate metabolic process, nuclear mRNA catabolic process, and neuron ensheathment. Brain metabolomics identified 14 increased features in Active participants, including N-acetylaspartylglutamic acid. Plasma proteomics and cytokine analyses revealed no differences. CONCLUSIONS Short-term everolimus before epilepsy surgery in TSC and FCD resulted in no adverse events and trending lower mTOR signaling (phospho-S6). Future studies should evaluate implications of our findings, including coagulation system activation and everolimus efficacy in FCD, in larger studies with long-term treatment to better understand molecular and clinical effects. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov NCT02451696.
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Affiliation(s)
- Dominique F. Leitner
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York, United States of America
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU School of Medicine, New York, New York, United States of America
| | - Manor Askenazi
- Biomedical Hosting LLC, Arlington, Massachusetts, United States of America
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, New York, United States of America
| | - Yik Siu
- Metabolomics Core Resource Laboratory, New York University School of Medicine, New York, New York, United States of America
| | - Daniel Friedman
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York, United States of America
| | - Sasha Devore
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York, United States of America
| | - Drew Jones
- Metabolomics Core Resource Laboratory, New York University School of Medicine, New York, New York, United States of America
| | - Beatrix Ueberheide
- Proteomics Laboratory, Division of Advanced Research Technologies, NYU School of Medicine, New York, New York, United States of America
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, New York, United States of America
- Center for Cognitive Neurology, Department of Neurology, New York University School of Medicine, New York, New York, United States of America
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Department of Neurology, New York University School of Medicine, New York, New York, United States of America
- Department of Psychiatry, New York University School of Medicine, New York, New York, United States of America
- Department of Pathology, New York University School of Medicine, New York, New York, United States of America
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York, United States of America
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