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Lazaro MJ, Alvaran A, Yun MH, Kim S. Mobile Health Application for Seizure Management: A Human-Systems Integration Approach. HUMAN FACTORS 2024; 66:744-769. [PMID: 35337190 DOI: 10.1177/00187208221074427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The study aims to develop a mHealth application for seizure management based on the human system integration (HSI) approach. BACKGROUND Unmet healthcare needs among people with epilepsy continue to exist despite the advancement in healthcare technology. Current seizure management methods are found to be ineffective. Therefore, a more efficient strategy such as mHealth technology is necessary to aid seizure management. METHOD The needs identification phase involved identifying the user requirements by interviewing 10 stakeholders and conducting thematic analysis and needs interpretation technique. In the solution identification phase, the system requirements were derived using various human-centered design and systems engineering approaches and were evaluated through quality function deployment to determine design targets. For the design and evaluation phase, the design targets were reflected in the app through the iterative prototyping process, and the interface and functional design were evaluated by seven human factors and ergonomics experts and four stakeholders, respectively. RESULTS Three primary needs and ten user requirements were derived from the needs identification phase. Ten out of fifteen system requirements were selected as design targets to be included in the final prototype. Results of the evaluation showed that the interface design of the proposed app showed superior usability compared to a competitor app and that the app functions were beneficial for the stakeholders. CONCLUSION The mHealth app designed through the HSI framework showed good potential in addressing the main issues in seizure management. APPLICATION The mHealth app design methodology based on the HSI approach can be applied to the design of small-scale systems in various domains.
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Affiliation(s)
- May Jorella Lazaro
- Interdisciplinary Program in Cognitive Science, Seoul National University, South Korea
| | | | - Myung Hwan Yun
- Department of Industrial Engineering & Institute for Industrial System Innovation, Seoul National University, Seoul, Korea
| | - Sungho Kim
- Department of Systems Engineering, Republic of Korea Air Force Academy, South Korea
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Singh T, Ramakrishnan S, Wu X, Reddy DS. Sex Differences in Organophosphate Model of Benzodiazepine-Refractory Status Epilepticus and Neuronal Damage. J Pharmacol Exp Ther 2024; 388:313-324. [PMID: 37770202 PMCID: PMC10801723 DOI: 10.1124/jpet.123.001747] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 10/03/2023] Open
Abstract
Sex differences are common in human epilepsy. Although men are more susceptible to seizure than women, the mechanisms underlying sex-specific vulnerabilities to seizure are unclear. The organophosphate (OP) diisopropylfluorophosphate (DFP) is known to cause neurotoxicity and status epilepticus (SE), a serious neurologic condition that causes prolonged seizures and brain damage. Current therapies for OP poisoning and SE do not consider neuronal variations between male and female brains. Therefore, we investigated sex-dependent differences in electrographic seizure activity and neuronal injury using the DFP model of refractory SE in rats. Electroencephalogram recordings were used to monitor DFP-induced SE, and the extent of brain injury was determined using fluoro-jade-B staining to detect cellular necrosis. After DFP exposure, we observed striking sex-dependent differences in SE and seizure activity patterns as well as protective responses to midazolam treatment. Following acute DFP exposure, male animals displayed more severe SE with intense epileptiform spiking and greater mortality than females. In contrast, we observed significantly more injured cells and cellular necrosis in the hippocampus and other brain regions in females than in males. We also observed extensive neuronal injury in the somatosensory cortex of males. The anticonvulsant effect of midazolam against SE was limited in this model and found to be similar in males and females. However, unlike males, females exhibited substantially more protection against neuronal damage after midazolam treatment. Overall, these results demonstrate significant sex-dependent differences in DFP-induced refractory SE and neuronal damage patterns, suggesting that it may be possible to develop sex-specific neuroprotective strategies for OP intoxication and refractory SE. SIGNIFICANCE STATEMENT: Sex-dependent differences in neurotoxicity and status epilepticus (SE) are key biological variables after organophosphate (OP) exposure. Here, we investigated sex-dependent differences in SE and brain injury after acute diisopropylfluorophosphate exposure. Male rats had more severe SE and less survival than females, while females had more neuronal damage. Females had more neuroprotection to midazolam than males, while both sexes had similar but partial anticonvulsant effects. These findings suggest that a sex-specific therapeutic approach may prevent neurological complications of OP-induced SE.
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Affiliation(s)
- Tanveer Singh
- Department of Neuroscience and Experimental Therapeutics and Institute of Pharmacology and Neurotherapeutics, Texas A&M University School of Medicine, Bryan, Texas
| | - Sreevidhya Ramakrishnan
- Department of Neuroscience and Experimental Therapeutics and Institute of Pharmacology and Neurotherapeutics, Texas A&M University School of Medicine, Bryan, Texas
| | - Xin Wu
- Department of Neuroscience and Experimental Therapeutics and Institute of Pharmacology and Neurotherapeutics, Texas A&M University School of Medicine, Bryan, Texas
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics and Institute of Pharmacology and Neurotherapeutics, Texas A&M University School of Medicine, Bryan, Texas
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Kim W, Lee H, Lee KW, Yang E, Kim S. The Association of Nocturnal Seizures and Interictal Cardiac/Central Autonomic Function in Frontal Lobe Epilepsy: Heart Rate Variability and Central Autonomic Network Analysis. Neuropsychiatr Dis Treat 2023; 19:2081-2091. [PMID: 37810949 PMCID: PMC10559795 DOI: 10.2147/ndt.s426263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose Patients with epilepsy frequently experience autonomic dysfunction, closely related to sudden unexplained death in epilepsy (SUDEP). SUDEP occurs most often at night or during sleep, and frequent nocturnal seizures are an established risk factor. This study investigated the influence of nocturnal seizures on autonomic dysfunction in epilepsy. Patients and Methods This retrospective study enrolled frontal lobe epilepsy (FLE) patients who performed 24-hour EEG monitoring. All participants were divided into nocturnal FLE (NFLE, > 90% of seizures occurring during sleep) or diurnal FLE (DFLE) groups. EEG and ECG signals were simultaneously obtained during waking and sleep stages. EEG current density source and connectivity analysis of the autonomic network were performed. ECG was analyzed across time and frequency domains heart rate variability (HRV) analysis method was used. The obtained parameters were compared between the NFLE and DFLE groups. Results Fifteen NFLE and 16 DFLE patients were enrolled with no significant difference in age, sex, disease duration, seizure frequency, or the number of anti-seizure medications between the two groups. During sleep, a decrease in HRV parameters and an increase of the beta-1 (13-22 Hz) current source density power in the bilateral paracentral lobule (BA4,5,6), precuneus (BA7), and cingulate (BA31) were observed in the NFLE group compared to DFLE group. The NFLE group also showed hyperconnectivity in the central autonomic (12 edges distributed over 10 nodes), sympathetic (2 edges distributed over 3 nodes), and parasympathetic (4 edges distributed over 6 nodes) beta-1 frequency band networks during sleep. During wakefulness, central and cardiac autonomic variables were not significantly different between the NFLE and DFLE groups. Conclusion Interictal cardiac and central autonomic dysfunction occurred simultaneously and can be attributed to the brain-heart autonomic axis. Our findings suggest that nocturnal seizures may contribute to interictal autonomic dysfunction during sleep in people with epilepsy.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyunjo Lee
- Department of Neurology, Ulsan University Hospital, College of Medicine, University of Ulsan, Ulsan, Republic of Korea
| | - Kyung Won Lee
- Department of Neurology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eunjin Yang
- Department of Neurology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seonghoon Kim
- Department of Neurology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Doerr JM, Juenemann M, Hakel L, Schmidt L, Menzler K, Krause K, Linka L, Skoluda N, Nater UM, Knake S. Effect of transcutaneous vagus nerve stimulation on stress-reactive neuroendocrine measures in a sample of persons with temporal lobe epilepsy. Epilepsia Open 2023; 8:1013-1020. [PMID: 37310988 PMCID: PMC10472404 DOI: 10.1002/epi4.12774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE Dysregulation of stress-reactive neuroendocrine measures, as well as subjective stress, have been found to worsen epilepsy. Transcutaneous vagus nerve stimulation (tVNS) is a relatively new treatment option for epilepsy. We were interested in its effect on the activity of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system (ANS) as well as subjective stress and tiredness in patients with temporal lobe epilepsy (TLE). METHODS Twenty patients (age 44 ± 11 years, 13 women) were enrolled in the study. They were free of seizures for more than 1 year. All took part in two sessions with 4 h of stimulation (tVNS vs. sham) in a randomized order. Saliva samples and subjective stress and tiredness levels were measured at five time points each session (before and after stimulation and three time points every hour in between). Data were analyzed using repeated measures analysis of variance as well as paired t-tests. RESULTS There was a dampened salivary cortisol (sCort) decrease during tVNS (time × condition effect: F[2.38, 38.15] = 6.50, P = 0.002, partial η2 = 0.29). Furthermore, we detected a dampened increase in salivary flow rate during tVNS (time × condition effect: F[3.28, 55.67] = 2.82, P = 0.043, partial η2 = 0.14). There was neither a difference in overall sCort or salivary alpha-amylase (sAA) levels nor in subjective stress or tiredness levels between conditions. sAA levels at the last measurement point were slightly higher during tVNS (t(19) = 2.26, P = 0.035, d = 0.51), but this effect failed to reach significance when controlled for multiple comparisons. SIGNIFICANCE Our results partially support that tVNS influences the regulation of stress-reactive neuroendocrine systems (namely the HPA axis and ANS) in epilepsy. More research with larger samples is needed on the difference between short-term and repeated long-term stimulation.
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Affiliation(s)
- Johanna M. Doerr
- Department of NeurologyUniversity Hospital Gießen and MarburgGießenGermany
| | - Martin Juenemann
- Department of NeurologyUniversity Hospital Gießen and MarburgGießenGermany
| | - Lukas Hakel
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Laura Schmidt
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Katja Menzler
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Kristina Krause
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Louise Linka
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
| | - Nadine Skoluda
- Department of Clinical and Health Psychology, Faculty of PsychologyUniversity of ViennaViennaAustria
| | - Urs M. Nater
- Department of Clinical and Health Psychology, Faculty of PsychologyUniversity of ViennaViennaAustria
| | - Susanne Knake
- Epilepsy Center Hessen, Department of NeurologyPhilipps‐University MarburgMarburgGermany
- Center for Mind, Brain and Behavior (CMBB)Philipps‐University MarburgMarburgGermany
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Casillas-Espinosa PM, Anderson A, Harutyunyan A, Li C, Lee J, Braine EL, Brady RD, Sun M, Huang C, Barlow CK, Shah AD, Schittenhelm RB, Mychasiuk R, Jones NC, Shultz SR, O'Brien TJ. Disease-modifying effects of sodium selenate in a model of drug-resistant, temporal lobe epilepsy. eLife 2023; 12:e78877. [PMID: 36892461 PMCID: PMC10208637 DOI: 10.7554/elife.78877] [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: 03/23/2022] [Accepted: 03/08/2023] [Indexed: 03/10/2023] Open
Abstract
There are no pharmacological disease-modifying treatments with an enduring effect to mitigate the seizures and comorbidities of established chronic temporal lobe epilepsy (TLE). This study aimed to evaluate for disease modifying effects of sodium selenate treatment in the chronically epileptic rat post-status epilepticus (SE) model of drug-resistant TLE. Wistar rats underwent kainic acid-induced SE or sham. Ten-weeks post-SE, animals received sodium selenate, levetiracetam, or vehicle subcutaneousinfusion continuously for 4 weeks. To evaluate the effects of the treatments, one week of continuous video-EEG was acquired before, during, and 4, 8 weeks post-treatment, followed by behavioral tests. Targeted and untargeted proteomics and metabolomics were performed on post-mortem brain tissue to identify potential pathways associated with modified disease outcomes. Telomere length was investigated as a novel surrogate marker of epilepsy disease severity in our current study. The results showed that sodium selenate treatment was associated with mitigation of measures of disease severity at 8 weeks post-treatment cessation; reducing the number of spontaneous seizures (p< 0.05), cognitive dysfunction (p< 0.05), and sensorimotor deficits (p< 0.01). Moreover, selenate treatment was associated with increased protein phosphatase 2A (PP2A) expression, reduced hyperphosphorylated tau, and reversed telomere length shortening (p< 0.05). Network medicine integration of multi-omics/pre-clinical outcomes identified protein-metabolite modules positively correlated with TLE. Our results provide evidence that treatment with sodium selenate results in a sustained disease-modifying effect in chronically epileptic rats in the post-KA SE model of TLE, including improved comorbid learning and memory deficits.
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Affiliation(s)
- Pablo M Casillas-Espinosa
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
- Monash Proteomics & Metabolomics Facility and Monash Biomedicine Discovery Institute, Monash UniversityClayton, VictoriaAustralia
| | - Alison Anderson
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Anna Harutyunyan
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Crystal Li
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Jiyoon Lee
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
| | - Emma L Braine
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Rhys D Brady
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Mujun Sun
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Cheng Huang
- Department of Neurology, The Alfred Hospital, Commercial Road,Melbourne, VictoriaAustralia
| | - Christopher K Barlow
- Department of Neurology, The Alfred Hospital, Commercial Road,Melbourne, VictoriaAustralia
| | - Anup D Shah
- Department of Neurology, The Alfred Hospital, Commercial Road,Melbourne, VictoriaAustralia
| | - Ralf B Schittenhelm
- Department of Neurology, The Alfred Hospital, Commercial Road,Melbourne, VictoriaAustralia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Nigel C Jones
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Sandy R Shultz
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
| | - Terence J O'Brien
- Department of Medicine, The Royal Melbourne Hospital, The University of MelbourneMelbourneAustralia
- Department of Neuroscience, Central Clinical School, Monash UniversityMelbourneAustralia
- Monash Proteomics & Metabolomics Facility and Monash Biomedicine Discovery Institute, Monash UniversityClayton, VictoriaAustralia
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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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Talavera B, Hupp NJ, Melius S, Lhatoo SD, Lacuey N. Protocols for multimodal polygraphy for cardiorespiratory monitoring in the epilepsy monitoring unit. Part I: Clinical acquisition. Epilepsy Res 2022; 185:106990. [PMID: 35930940 DOI: 10.1016/j.eplepsyres.2022.106990] [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] [Indexed: 11/03/2022]
Abstract
Multimodal polygraphy including cardiorespiratory monitoring in the Epilepsy Monitoring is becoming increasingly important. In addition to simultaneous recording of video and EEG, the combination of these techniques not only improves seizure detection, it enhances patient safety and provides information on autonomic clinical symptoms, which may be contributory to localization of seizure foci. However, there are currently no consensus guidelines, nor adequate information on devices available for multimodal polygraphy for cardiorespiratory monitoring in the Epilepsy Monitoring Unit. Our purpose here is to provide protocols and information on devices for such monitoring. Suggested parameters include respiratory inductance plethysmography (thoraco-abdominal belts for respiratory rate), pulse oximetry and four-lead electrocardiography. Detailed knowledge of devices, their operability and acquisition optimization enables accurate interpretation of signal and differentiation of abnormalities from artifacts. Multimodal polygraphy brings new opportunities for identification of peri-ictal cardiorespiratory abnormalities, and may identify high SUDEP risk individuals.
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Affiliation(s)
- Blanca Talavera
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA.
| | - Norma J Hupp
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Stephen Melius
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Samden D Lhatoo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
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Joyal KG, Kreitlow BL, Buchanan GF. The role of sleep state and time of day in modulating breathing in epilepsy: implications for sudden unexpected death in epilepsy. Front Neural Circuits 2022; 16:983211. [PMID: 36082111 PMCID: PMC9445500 DOI: 10.3389/fncir.2022.983211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death among patients with refractory epilepsy. While the exact etiology of SUDEP is unknown, mounting evidence implicates respiratory dysfunction as a precipitating factor in cases of seizure-induced death. Dysregulation of breathing can occur in epilepsy patients during and after seizures as well as interictally, with many epilepsy patients exhibiting sleep-disordered breathing (SDB), such as obstructive sleep apnea (OSA). The majority of SUDEP cases occur during the night, with the victim found prone in or near a bed. As breathing is modulated in both a time-of-day and sleep state-dependent manner, it is relevant to examine the added burden of nocturnal seizures on respiratory function. This review explores the current state of understanding of the relationship between respiratory function, sleep state and time of day, and epilepsy. We highlight sleep as a particularly vulnerable period for individuals with epilepsy and press that this topic warrants further investigation in order to develop therapeutic interventions to mitigate the risk of SUDEP.
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Affiliation(s)
- Katelyn G. Joyal
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Benjamin L. Kreitlow
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Medical Scientist Training Program, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Gordon F. Buchanan
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Medical Scientist Training Program, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- *Correspondence: Gordon F. Buchanan
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Venegas V, Manterola C, De Pablo J, Garcia M, Ponce de León S, Cavada G. How the characteristics of pediatric neurologists in Latin America influence the communication of sudden unexpected death in epilepsy to patients and caregivers. Epilepsia Open 2022; 7:442-451. [PMID: 35726385 PMCID: PMC9436282 DOI: 10.1002/epi4.12620] [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: 03/31/2022] [Accepted: 06/17/2022] [Indexed: 11/24/2022] Open
Abstract
Objective This study aimed to describe the characteristics of pediatric neurologists (PNs) in Latin America (LA) who attend to children and adolescents with epilepsy and convey to them the risk of sudden unexpected death in epilepsy (SUDEP). Methods Personal data and details of discussion of SUDEP with families, including relevance of SUDEP disclosure, frequency of such communication, perceived benefits and risks of disclosure, extent of training received on such disclosure, and professional experience with SUDEP, were collected through an online survey of PNs from LA. Their personal experience in carrying out this conversation was obtained through responses to an open question, further used to identify the main barriers. Results Of the 442 surveys received, 367 (83%) were analyzed. Most participants (73.8%) responded that the communication of SUDEP risk was relevant or very relevant; however, only 17.9% reported communicating it always or very frequently. Factors that increased the frequency of SUDEP communication included patients with higher levels of complexity (OR = 2.18, P = .003) and the physician's personal experience with SUDEP (OR = 2.305, P < .001). Direct questions from the family and avoiding scaring them about a rare outcome were the main motivations behind discussing and not discussing SUDEP, respectively. In the open question, respondents identified worries about the patient's ability to understand the information and cultural gaps as barriers. “Informing with the intention of improving adherence to treatment” and “establishing an empathic relationship” were significantly related. Further, the concept of “do not scare” was significantly related to “personal difficulties in discussing SUDEP.” Significance Although most PNs agree that communication about SUDEP is relevant, only a minority actually engages in it. Participants identified a lack of appropriate training in such communication as a barrier. A better understanding of communication expectations, education of health professionals, and communication techniques have a strong relevance in diminishing the gap between guidelines and practice.
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Affiliation(s)
- Viviana Venegas
- Unit of Pediatric Neurology, Faculty of Medicine Universidad del Desarrollo, Clinica Alemana de Santiago, Chile.,Unit of Neurophysiology, Neurosurgery Institute Dr. Alfonso Asenjo
| | - Carla Manterola
- Unit of Pediatric Neurology, Faculty of Medicine Universidad del Desarrollo, Clinica Alemana de Santiago, Chile.,Faculty of Medicine, Universidad de Chile, Hospital Dr. Luis Calvo Mackenna
| | - Jose De Pablo
- Unit of Neurophysiology, Neurosurgery Institute Dr. Alfonso Asenjo
| | | | - Sonia Ponce de León
- Unit of Pediatric Neurology, Faculty of Medicine Universidad del Desarrollo, Clinica Alemana de Santiago, Chile.,Unit of Neurophysiology, Neurosurgery Institute Dr. Alfonso Asenjo
| | - Gabriel Cavada
- Faculty of Medicine, Universidad de Chile.,Unit of Clinical Research, Clinica Alemana de Santiago, Chile
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Alotaibi AS, Mahroos RA, Al Yateem SS, Menezes RG. Central Nervous System Causes of Sudden Unexpected Death: A Comprehensive Review. Cureus 2022; 14:e20944. [PMID: 35004089 PMCID: PMC8730823 DOI: 10.7759/cureus.20944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 01/03/2023] Open
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Scorza FA, de Almeida ACG, Scorza CA, Finsterer J. Sudden unexpected death in epilepsy and abnormal glucose metabolism in the rat insular cortex: A brain within the heart. Clinics (Sao Paulo) 2022; 77:100059. [PMID: 35905578 PMCID: PMC9335350 DOI: 10.1016/j.clinsp.2022.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Fulvio A Scorza
- Disciplina de Neurociência, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil; Centro de Neurociências e Saúde da Mulher "Professor Geraldo Rodrigues de Lima", Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil.
| | - Antonio-Carlos G de Almeida
- Centro de Neurociências e Saúde da Mulher "Professor Geraldo Rodrigues de Lima", Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil; Laboratório de Neurociência Experimental e Computacional, Departamento de Engenharia de Biossistemas, Universidade Federal de São João del-Rei (UFSJ), São João del-Rei, MG, Brazil
| | - Carla A Scorza
- Disciplina de Neurociência, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil; Centro de Neurociências e Saúde da Mulher "Professor Geraldo Rodrigues de Lima", Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
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da Silva Fiorin F, de Araújo E Silva M, Rodrigues AC. Electrical stimulation in animal models of epilepsy: A review on cellular and electrophysiological aspects. Life Sci 2021; 285:119972. [PMID: 34560081 DOI: 10.1016/j.lfs.2021.119972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 01/24/2023]
Abstract
Epilepsy is a debilitating condition, primarily refractory individuals, leading to the search for new efficient therapies. Electrical stimulation is an important method used for years to treat several neurological disorders. Currently, electrical stimulation is used to reduce epileptic crisis in patients and shows promising results. Even though the use of electricity to treat neurological disorders has grown worldwide, there are still many caveats that must be clarified, such as action mechanisms and more efficient stimulation treatment parameters. Thus, this review aimed to explore the comprehension of the main stimulation methods in animal models of epilepsy using rodents to develop new experimental protocols and therapeutic approaches.
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Affiliation(s)
- Fernando da Silva Fiorin
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil.
| | - Mariane de Araújo E Silva
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
| | - Abner Cardoso Rodrigues
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
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13
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D'Imperio S, Monasky MM, Micaglio E, Ciconte G, Anastasia L, Pappone C. Brugada Syndrome: Warning of a Systemic Condition? Front Cardiovasc Med 2021; 8:771349. [PMID: 34722688 PMCID: PMC8553994 DOI: 10.3389/fcvm.2021.771349] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
Brugada syndrome (BrS) is a hereditary disorder, characterized by a specific electrocardiogram pattern and highly related to an increased risk of sudden cardiac death. BrS has been associated with other cardiac and non-cardiac pathologies, probably because of protein expression shared by the heart and other tissue types. In fact, the most commonly found mutated gene in BrS, SCN5A, is expressed throughout nearly the entire body. Consistent with this, large meals and alcohol consumption can trigger arrhythmic events in patients with BrS, suggesting a role for organs involved in the digestive and metabolic pathways. Ajmaline, a drug used to diagnose BrS, can have side effects on non-cardiac tissues, such as the liver, further supporting the idea of a role for organs involved in the digestive and metabolic pathways in BrS. The BrS electrocardiogram (ECG) sign has been associated with neural, digestive, and metabolic pathways, and potential biomarkers for BrS have been found in the serum or plasma. Here, we review the known associations between BrS and various organ systems, and demonstrate support for the hypothesis that BrS is not only a cardiac disorder, but rather a systemic one that affects virtually the whole body. Any time that the BrS ECG sign is found, it should be considered not a single disease, but rather the final step in any number of pathways that ultimately threaten the patient's life. A multi-omics approach would be appropriate to study this syndrome, including genetics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and glycomics, resulting eventually in a biomarker for BrS and the ability to diagnose this syndrome using a minimally invasive blood test, avoiding the risk associated with ajmaline testing.
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Affiliation(s)
- Sara D'Imperio
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Michelle M Monasky
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Emanuele Micaglio
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Giuseppe Ciconte
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Luigi Anastasia
- Faculty of Medicine and Surgery, University of Vita-Salute San Raffaele, Milan, Italy
| | - Carlo Pappone
- Arrhythmology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy.,Faculty of Medicine and Surgery, University of Vita-Salute San Raffaele, Milan, Italy
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14
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Zhu C, Kim Y, Jiang X, Lhatoo S, Jaison H, Zhang GQ. A lightweight convolutional neural network for assessing an EEG risk marker for sudden unexpected death in epilepsy. BMC Med Inform Decis Mak 2020; 20:329. [PMID: 33357242 PMCID: PMC7758925 DOI: 10.1186/s12911-020-01310-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Convolutional neural network (CNN) has achieved state-of-art performance in many electroencephalogram (EEG) related studies. However, the application of CNN in prediction of risk factors for sudden unexpected death in epilepsy (SUDEP) remains as an underexplored area. It is unclear how the trade-off between computation cost and prediction power varies with changes in the complexity and depth of neural nets. METHODS The purpose of this study was to explore the feasibility of using a lightweight CNN to predict SUDEP. A total of 170 patients were included in the analyses. The CNN model was trained using clips with 10-s signals sampled from the original EEG. We implemented Hann function to smooth the raw EEG signal and evaluated its effect by choosing different strength of denoising filter. In addition, we experimented two variations of the proposed model: (1) converting EEG input into an "RGB" format to address EEG channels underlying spatial correlation and (2) incorporating residual network (ResNet) into the bottle neck position of the proposed structure of baseline CNN. RESULTS The proposed baseline CNN model with lightweight architecture achieved the best AUC of 0.72. A moderate noise removal step facilitated the training of CNN model by ensuring stability of performance. We did not observe further improvement in model's accuracy by increasing the strength of denoising filter. CONCLUSION Post-seizure slow activity in EEG is a potential marker for SUDEP, our proposed lightweight architecture of CNN achieved satisfying trade-off between efficiently identifying such biomarker and computational cost. It also has a flexible interface to be integrated with different variations in structure leaving room for further improvement of the model's performance in automating EEG signal annotation.
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Affiliation(s)
- Cong Zhu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yejin Kim
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xiaoqian Jiang
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Samden Lhatoo
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hampson Jaison
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Guo-Qiang Zhang
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
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15
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Stewart M, Silverman JB, Sundaram K, Kollmar R. Causes and Effects Contributing to Sudden Death in Epilepsy and the Rationale for Prevention and Intervention. Front Neurol 2020; 11:765. [PMID: 32849221 PMCID: PMC7411179 DOI: 10.3389/fneur.2020.00765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) claims the lives of one in every thousand epileptic patients each year. Autonomic, cardiac, and respiratory pieces to a mechanistic puzzle have not yet been completely assembled. We propose a single sequence of causes and effects that unifies disparate and competitive concepts into a single algorithm centered on ictal obstructive apnea. Based on detailed animal studies that are sometimes impossible in humans, and striking parallels with a growing body of clinical examples, this framework (1) accounts for the autonomic, cardiac, and respiratory data to date by showing the causal relationships between specific elements, and (2) highlights specific kinds of data that can be used to precisely classify various patient outcomes. The framework also justifies a “near miss” designation to be applied to any cases with evidence of obstructive apnea even, and perhaps especially, in individuals that do not require resuscitation. Lastly, the rationale for preventative oxygen therapy is demonstrated. With better mechanistic understanding of SUDEP, we suggest changes for detection and classification to increase survival rates and improve risk stratification.
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Affiliation(s)
- Mark Stewart
- Department of Neurology, State University of New York Health Sciences University, Brooklyn, NY, United States.,Department of Physiology & Pharmacology, State University of New York Health Sciences University, Brooklyn, NY, United States
| | - Joshua B Silverman
- Department of Otolaryngology, North Shore Long Island Jewish Medical Center, New Hyde Park, NY, United States
| | - Krishnamurthi Sundaram
- Department of Otolaryngology, State University of New York Health Sciences University, Brooklyn, NY, United States
| | - Richard Kollmar
- Department of Otolaryngology, State University of New York Health Sciences University, Brooklyn, NY, United States.,Department of Cell Biology, State University of New York Health Sciences University, Brooklyn, NY, United States
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16
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Pensel MC, Nass RD, Taubøll E, Aurlien D, Surges R. Prevention of sudden unexpected death in epilepsy: current status and future perspectives. Expert Rev Neurother 2020; 20:497-508. [PMID: 32270723 DOI: 10.1080/14737175.2020.1754195] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Sudden unexpected death in epilepsy (SUDEP) affects about 1 in 1000 people with epilepsy, and even more in medically refractory epilepsy. As most people are between 20 and 40 years when dying suddenly, SUDEP leads to a considerable loss of potential life years. The most important risk factors are nocturnal and tonic-clonic seizures, underscoring that supervision and effective seizure control are key elements for SUDEP prevention. The question of whether specific antiepileptic drugs are linked to SUDEP is still controversially discussed. Knowledge and education about SUDEP among health-care professionals, patients, and relatives are of outstanding importance for preventive measures to be taken, but still poor and widely neglected.Areas covered: This article reviews epidemiology, pathophysiology, risk factors, assessment of individual SUDEP risk and available measures for SUDEP prevention. Literature search was done using Medline and Pubmed in October 2019.Expert opinion: Significant advances in the understanding of SUDEP were made in the last decade which allow testing of novel strategies to prevent SUDEP. Promising current strategies target neuronal mechanisms of brain stem dysfunction, cardiac susceptibility for fatal arrhythmias, and reliable detection of tonic-clonic seizures using mobile health technologies.Abbreviations: AED, antiepileptic drug; CBZ, carbamazepine; cLQTS, congenital long QT syndrome; EMU, epilepsy monitoring unit; FBTCS, focal to bilateral tonic-clonic seizures; GTCS, generalized tonic-clonic seizures; ICA, ictal central apnea; LTG, lamotrigine; PCCA, postconvulsive central apnea; PGES, postictal generalized EEG suppression; SRI, serotonin reuptake inhibitor; SUDEP, sudden unexpected death in epilepsy; TCS, tonic-clonic seizures.
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Affiliation(s)
| | | | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Nydalen, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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17
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Mahr K, Bergmann MP, Kay L, Möller L, Reif PS, Willems LM, Menzler K, Schubert-Bast S, Klein KM, Knake S, Rosenow F, Zöllner JP, Strzelczyk A. Prone, lateral, or supine positioning at seizure onset determines the postictal body position: A multicenter video-EEG monitoring cohort study. Seizure 2020; 76:173-178. [PMID: 32109735 DOI: 10.1016/j.seizure.2020.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Most patients who die from sudden unexpected death in epilepsy (SUDEP) are found in the prone position. We evaluated whether changes in body position occur during generalized convulsive seizures (GCSs). METHOD GCSs in patients undergoing video-EEG-monitoring between 2007 and 2017 at epilepsy centers in Frankfurt and Marburg were analyzed in relation to changes in body position. RESULTS A total of 494 GCSs were analyzed among 327 patients. At seizure onset, positions included supine (48.2 %), right lateral (19.0 %), left lateral (15.6 %), sitting or standing (14.0 %), and prone (3.2 %). Between seizure onset and the start of generalization, 57.5 % of participants altered body positions. During four seizures, patients adopted a prone position, while, in five seizures, patients moved from a prone position. Patients who experienced GCS onset while in a nonprone position had a 2.1 % risk of entering the prone position by the end of their seizure. In contrast, 56.2 % of those in an initial prone position remained so at the end of the GCS, with an odds ratio for maintaining that position of 60.2 (95 % confidence interval: 29.1-124.3; p < 0.001). The likelihood of ending up in the prone position post-GCS did not vary among patients with different nonprone starting positions (p = 0.147). CONCLUSIONS Seizures in prone position occur during sleep and the highest risk for postictal prone positioning appears to be being in the prone position at GCS onset. Epilepsy patients should therefore be advised to go to sleep in a supine or lateral position to reduce their SUDEP risk.
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Affiliation(s)
- Katharina Mahr
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Marc-Philipp Bergmann
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Lara Kay
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Leona Möller
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Philipp S Reif
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Katja Menzler
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Department of Neuropediatrics, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karl Martin Klein
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Departments of Clinical Neurosciences, Medical Genetics and Community Health Sciences, Hotchkiss Brain Institute & Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susanne Knake
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Johann Philipp Zöllner
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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18
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Evaluation of Cardiac Repolarization Indices in Epilepsy Patients Treated with Carbamazepine and Valproic Acid. ACTA ACUST UNITED AC 2020; 56:medicina56010020. [PMID: 31935975 PMCID: PMC7022319 DOI: 10.3390/medicina56010020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/20/2019] [Accepted: 01/03/2020] [Indexed: 11/25/2022]
Abstract
Background and Objectives: Epilepsy patients have a higher risk of sudden unexplained death compared to the rest of the population. Cardiac repolarization abnormalities might be seen in epilepsy during interictal periods. We aimed to evaluate the changes in electrocardiography (ECG) parameters in generalized tonic-clonic seizure patients treated with carbamazepine or valproic acid (VPA) drug. Materials and Methods: A totally of 129 subjects (66 epilepsy patients, 63 healthy subjects) were enrolled in the study. Of the patients, 36 were on carbamazepine and 30 were on VPA. There were 12-lead ECGs obtained from all participants. RR interval (time between consecutive R peaks), QT interval (defines the period of ventricular repolarization), corrected QT (QT interval corrected for heart rate; QTc), QTc-maximum (QTc-max), QTc-minimum (QTc-min), QTc dispersion (QTcd), P (atrial depolarization )-maximum (P-max), P-minimum (P-min) and P dispersion (Pd) were measured. Results: QTd (QT dispersion), QTcd, and Pd values were significantly higher in the patients compared to the controls (p < 0.01). QTcd, Pd, and P-max values were statistically higher in male patients compared to healthy male controls. QTcd values were significantly higher in female patients using carbamazepine compared to the female patients on VPA and healthy controls (p = 0.01). Male patients using VPA had significantly higher QTcd values against the male population in carbamazepine and control groups. Conclusions: This study demonstrated that QTd, QTcd, and Pd values were significantly higher in epilepsy patients than in healthy controls. In addition, female patients using carbamazepine and male patients using VPA were prone to ventricular arrhythmia compared to the control group.
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19
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Scorza CA, Guimarães-Marques M, Girão ERC, Nejm M, Finsterer J, Girão MJBC, Younes RN, Laranjeira RR, Scorza FA. Alcohol and sudden unexpected death in epilepsy: do not pop the cork. Clinics (Sao Paulo) 2020; 75:e1770. [PMID: 32401968 PMCID: PMC7196729 DOI: 10.6061/clinics/2020/e1770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/03/2020] [Indexed: 01/03/2023] Open
Affiliation(s)
- Carla A Scorza
- Disciplina de Neurociencia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Marcia Guimarães-Marques
- Disciplina de Neurociencia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Eduardo R C Girão
- Disciplina de Neurociencia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Mariana Nejm
- Disciplina de Neurociencia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
| | - Josef Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute. Vienna, AustriaAustria
| | - Manoel J B C Girão
- Departamento de Ginecologia. Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/UNIFESP), Sao Paulo, SP, BR
| | - Riad N Younes
- Centro de Oncologia, Hospital Alemao Oswaldo Cruz, Sao Paulo, SP, BR
| | - Ronaldo R Laranjeira
- Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/UNIFESP), Sao Paulo, SP, BR
| | - Fulvio A Scorza
- Disciplina de Neurociencia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (UNIFESP), Sao Paulo, SP, BR
- Corresponding author. E-mail:
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20
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Herath J, Liu O. Sudden Natural Deaths in Ontario, Canada: A Retrospective Autopsy Analysis (2012–2016). JOURNAL OF FORENSIC SCIENCE AND MEDICINE 2020. [DOI: 10.4103/jfsm.jfsm_50_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Cardiac stress after electroconvulsive therapy and spontaneous generalized convulsive seizures: A prospective echocardiographic and blood biomarker study. Epilepsy Behav 2019; 101:106565. [PMID: 31675603 DOI: 10.1016/j.yebeh.2019.106565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 11/21/2022]
Abstract
AIM Knowledge about cardiac stress related to seizures in electroconvulsive therapy (ECT) and spontaneously occurring generalized convulsive seizures (GCS) is limited. The aim of the present study was to analyze cardiac function and circulating markers of cardiac stress in the early postictal period after ECT and GCS. METHODS Patients undergoing ECT in the Department of Psychiatry, Psychotherapy and Psychosomatics and patients undergoing diagnostic video-EEG monitoring (VEM) in the Department of Neurology were prospectively enrolled between November 2017 and November 2018. Cardiac function was examined twice using transthoracic echocardiography within 60 min and >4 h after ECT or GCS. Established blood markers (troponin T high-sensitive, N-terminal pro brain natriuretic peptide) of cardiac stress or injury were collected within 30 min, 4 to 6 h, and 24 h after ECT or GCS. In the ECT group, the troponin T values were also correlated with periprocedural heart rate and blood pressure values. Because of organizational or technical reasons, the measurement was not performed in all patients. RESULTS Twenty patients undergoing ECT and 6 patients with epilepsy with a GCS during VEM were included. Postictal echocardiography showed no wall motion disorders and no change in left ventricular and right ventricular functions. Four of 17 patients displayed a transient increase in high-sensitive cardiac troponin T 4-6 h after the seizure (3 patients with ECT-induced seizure). None of these 4 patients had signs of an acute cardiac event, and periprocedural blood pressure or heart rate peaks during ECT did not significantly differ in patients with and without troponin T elevation. CONCLUSIONS Signs of mild cardiac stress can occur in some patients following ECT or GCS without clinical complications, probably related to excessive catecholamine release during the seizure.
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22
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LA A, Rm H, M G, R K, Ja O, Sb V, S O, Ca S, Sd L, L L, B D. Altered brain connectivity in sudden unexpected death in epilepsy (SUDEP) revealed using resting-state fMRI. NEUROIMAGE-CLINICAL 2019; 24:102060. [PMID: 31722289 PMCID: PMC6849487 DOI: 10.1016/j.nicl.2019.102060] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 01/12/2023]
Abstract
The functional architecture among regulatory structures, and the whole brain, is less modular in confirmed cases of SUDEP and those at high-risk. Altered functional organisation may mean potential impairment of communication among key regulatory circuits. SUDEP is associated with regional connectivity disruptions among cortical and sub-cortical regulatory sites. Medial thalamic connectivity was significantly altered in SUDEP compared with all control groups, including those at high-risk. Increases in the number, and a shift in organisation, of hubs appears to relate to lower mortality risk.
The circumstances surrounding SUDEP suggest autonomic or respiratory collapse, implying central failure of regulation or recovery. Characterisation of the communication among brain areas mediating such processes may shed light on mechanisms and noninvasively indicate risk. We used rs-fMRI to examine network properties among brain structures in people with epilepsy who suffered SUDEP (n = 8) over an 8-year follow-up period, compared with matched high- and low-risk subjects (n = 16/group) who did not suffer SUDEP during that period, and a group of healthy controls (n = 16). Network analysis was employed to explore connectivity within a ‘regulatory-subnetwork’ of brain regions involved in autonomic and respiratory regulation, and over the whole-brain. Modularity, the extent of network organization into separate modules, was significantly reduced in the regulatory-subnetwork, and the whole-brain, in SUDEP and high-risk. Increased participation, a local measure of inter-modular belonging, was evident in SUDEP and high-risk groups, particularly among thalamic structures. The medial prefrontal thalamus was increased in SUDEP compared with all other control groups, including high-risk. Patterns of hub topology were similar in SUDEP and high-risk, but were more extensive in low-risk patients, who displayed greater hub prevalence and a radical reorganization of hubs in the subnetwork. SUDEP is associated with reduced functional organization among cortical and sub-cortical brain regions mediating autonomic and respiratory regulation. Living high-risk subjects demonstrated similar patterns, suggesting such network measures may provide prospective risk-indicating value, though a crucial difference between SUDEP and high-risk was altered connectivity of the medial thalamus in SUDEP, which was also elevated compared with all sub-groups. Disturbed thalamic connectivity may reflect a potential non-invasive marker of elevated SUDEP risk.
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Affiliation(s)
- Allen LA
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Harper Rm
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; UCLA Brain Research Institute, Los Angeles, CA, USA; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Guye M
- Aix Marseille University, CNRS, CRMBM UMR 7339, Marseille, France
| | - Kumar R
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Bioengineering, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ogren Ja
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; UCLA Brain Research Institute, Los Angeles, CA, USA
| | - Vos Sb
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; UCLA Brain Research Institute, Los Angeles, CA, USA; Wellcome / EPSRC Centre Interventional and Surgical Sciences, UCL, London, UK; Translational Imaging Group, Centre for Medical Image Computing, UCL, London, UK
| | - Ourselin S
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, London, UK
| | - Scott Ca
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Lhatoo Sd
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Lemieux L
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK
| | - Diehl B
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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de Bézenac C, Garcia-Finana M, Baker G, Moore P, Leek N, Mohanraj R, Bonilha L, Richardson M, Marson AG, Keller S. Investigating imaging network markers of cognitive dysfunction and pharmacoresistance in newly diagnosed epilepsy: a protocol for an observational cohort study in the UK. BMJ Open 2019; 9:e034347. [PMID: 31619436 PMCID: PMC6797398 DOI: 10.1136/bmjopen-2019-034347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Epilepsy is one of the most common serious brain disorders, characterised by seizures that severely affect a person's quality of life and, frequently, their cognitive and mental health. Although most existing work has examined chronic epilepsy, newly diagnosed patients present a unique opportunity to understand the underlying biology of epilepsy and predict effective treatment pathways. The objective of this prospective cohort study is to examine whether cognitive dysfunction is associated with measurable brain architectural and connectivity impairments at diagnosis and whether the outcome of antiepileptic drug treatment can be predicted using these measures. METHODS AND ANALYSIS 107 patients with newly diagnosed focal epilepsy from two National Health Service Trusts and 48 healthy controls (aged 16-65 years) will be recruited over a period of 30 months. Baseline assessments will include neuropsychological evaluation, structural and functional Magnetic Resonance Imaging (MRI), Electroencephalography (EEG), and a blood and saliva sample. Patients will be followed up every 6 months for a 24-month period to assess treatment outcomes. Connectivity- and network-based analyses of EEG and MRI data will be carried out and examined in relation to neuropsychological evaluation and patient treatment outcomes. Patient outcomes will also be investigated with respect to analysis of molecular isoforms of high mobility group box-1 from blood and saliva samples. ETHICS AND DISSEMINATION This study was approved by the North West, Liverpool East Research Ethics Committee (19/NW/0384) through the Integrated Research Application System (Project ID 260623). Health Research Authority (HRA) approval was provided on 22 August 2019. The project is sponsored by the UoL (UoL001449) and funded by a UK Medical Research Council (MRC) research grant (MR/S00355X/1). Findings will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER IRAS Project ID 260623.
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Affiliation(s)
- Christophe de Bézenac
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Gus Baker
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Perry Moore
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Nicola Leek
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rajiv Mohanraj
- Department of Neurology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Leonardo Bonilha
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mark Richardson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony Guy Marson
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon Keller
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Barbour K, Hesdorffer DC, Tian N, Yozawitz EG, McGoldrick PE, Wolf S, McDonough TL, Nelson A, Loddenkemper T, Basma N, Johnson SB, Grinspan ZM. Automated detection of sudden unexpected death in epilepsy risk factors in electronic medical records using natural language processing. Epilepsia 2019; 60:1209-1220. [PMID: 31111463 DOI: 10.1111/epi.15966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/25/2019] [Accepted: 04/25/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability. METHODS Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic-clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F-measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three "boilerplate" standard text phrases from away notes and repeated performance. RESULTS We observed high performance in home test data (F-measure range = 0.86-0.90), and low to high performance in away test data (F-measure range = 0.53-0.81). After removing three boilerplate phrases, away performance improved (F-measure range = 0.79-0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data. SIGNIFICANCE Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling.
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Affiliation(s)
- Kristen Barbour
- Division of Child Neurology, Weill Cornell Medicine, New York, New York
| | - Dale C Hesdorffer
- Department of Epidemiology, Columbia University Medical Center, New York, New York
| | - Niu Tian
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elissa G Yozawitz
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York
| | | | - Steven Wolf
- Department of Neurology, Mount Sinai Health System, New York, New York
| | - Tiffani L McDonough
- Department of Epidemiology, Columbia University Medical Center, New York, New York
| | - Aaron Nelson
- Department of Neurology, New York University Langone Medical Center, New York, New York
| | | | - Natasha Basma
- Division of Child Neurology, Weill Cornell Medicine, New York, New York
| | - Stephen B Johnson
- Division of Child Neurology, Weill Cornell Medicine, New York, New York
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Nass RD, Hampel KG, Elger CE, Surges R. Blood Pressure in Seizures and Epilepsy. Front Neurol 2019; 10:501. [PMID: 31139142 PMCID: PMC6527757 DOI: 10.3389/fneur.2019.00501] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/25/2019] [Indexed: 12/18/2022] Open
Abstract
In this narrative review, we summarize the current knowledge of neurally mediated blood pressure (BP) control and discuss how recently described epilepsy- and seizure-related BP alterations may contribute to premature mortality and sudden unexpected death in epilepsy (SUDEP). Although people with epilepsy display disturbed interictal autonomic function with a shift toward predominant sympathetic activity, prevalence of arterial hypertension is similar in people with and without epilepsy. BP is transiently increased in association with most types of epileptic seizures but may also decrease in some, illustrating that seizure activity can cause both a decrease and increase of BP, probably because of stimulation or inhibition of distinct central autonomic function by epileptic activity that propagates into different neuronal networks of the central autonomic nervous system. The principal regulatory neural loop for short-term BP control is termed baroreflex, mainly involving peripheral sensors and brain stem nuclei. The baroreflex sensitivity (BRS, expressed as change of interbeat interval per change in BP) is intact after focal seizures, whereas BRS is markedly impaired in the early postictal period following generalized convulsive seizures (GCS), possibly due to metabolically mediated muscular hyperemia in skeletal muscles, a massive release of catecholamines and compromised brain stem function. Whilst most SUDEP cases are probably caused by a cardiorespiratory failure during the early postictal period following GCS, a profoundly disturbed BRS may allow a life-threatening drop of systemic BP in the aftermath of GCS, as recently reported in a patient as a plausible cause of SUDEP in a few patients.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kevin G Hampel
- Department of Neurology, University Hospital La Fe, Valencia, Spain
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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26
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Mahdavi Y, Surges R, Nikoubashman O, Olaciregui Dague K, Brokmann JC, Willmes K, Wiesmann M, Schulz JB, Matz O. Neurogenic pulmonary edema following seizures: A retrospective computed tomography study. Epilepsy Behav 2019; 94:112-117. [PMID: 30901571 DOI: 10.1016/j.yebeh.2019.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/08/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Data on the frequency and clinical relevance of neurogenic pulmonary edema (NPE) following epileptic seizures are limited. The aim of the present study was to analyze computed tomography (CT) examinations in patients with previous seizures. METHOD Incidence of NPE and related clinical factors were retrospectively assessed in patients admitted because of epileptic seizures who underwent thoracic CT imaging as part of emergency diagnostics. RESULTS Between January 2010 and January 2016, we included all patients admitted with the International Classification of Diseases (ICD) diagnosis code of epileptic seizure or epilepsy and who underwent CT imaging, including visualization of the lungs, as part of emergency diagnostics. Of the 47 included patients, 26 patients had suffered from generalized convulsive seizures (GCS), 17 patients had focal seizures with impaired and 4 without impaired consciousness. Signs of NPE were present in 5 out of 47 patients; all 5 patients had GCS prior to thoracic CT scan (i.e., 19% of patients with GCS). In four out of five cases, a single seizure was described; in one case, the seizure was only partially witnessed, but the indirect clinical signs strongly suggested a GCS. Related factors such as the initial respiratory rate or the initial pCO2 value were not significantly different in patients with and without signs of NPE. CONCLUSIONS The highly selected and biased patient group warrants caution in the interpretation of the study results. Our data, however, confirm that signs of NPE appear to be rather frequent in patients with GCS. Its clinical significance as regards morbidity and sudden death in epilepsy is discussed.
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Affiliation(s)
- Yasser Mahdavi
- Department of Neuroradiology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Rainer Surges
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Karmele Olaciregui Dague
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Jörg C Brokmann
- Emergency Department, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Klaus Willmes
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Oliver Matz
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany; Emergency Department, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany.
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27
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Diving responses elicited by nasopharyngeal irrigation mimic seizure-associated central apneic episodes in a rat model. Neurobiol Dis 2019; 124:408-415. [DOI: 10.1016/j.nbd.2018.12.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/28/2018] [Accepted: 12/24/2018] [Indexed: 01/09/2023] Open
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Scorza FA, Olszewer E, Fiorini AC, Scorza CA, Finsterer J. Sudden unexpected death in epilepsy: Rethinking the unthinkable. Epilepsy Behav 2019; 93:148-149. [PMID: 30661917 DOI: 10.1016/j.yebeh.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 01/01/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Fulvio A Scorza
- Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil.
| | - Efraín Olszewer
- Fundação de Apoio à Pesquisa e Estudos na Área de Saúde - FAPES, Brazil
| | - Ana C Fiorini
- Programa de Estudos Pós-Graduado em Fonoaudiologia, Pontifícia Universidade Católica de São Paulo (PUC-SP), Brazil; Departamento de Fonoaudiologia, Escola Paulista de Medicina/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, Brazil.
| | - Carla A Scorza
- Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brazil
| | - Josef Finsterer
- Krankenanstalt Rudolfstiftung, Vienna, Messerli Institute, Veterinary University of Vienna, Vienna, Austria
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Allen LA, Vos SB, Kumar R, Ogren JA, Harper RK, Winston GP, Balestrini S, Wandschneider B, Scott CA, Ourselin S, Duncan JS, Lhatoo SD, Harper RM, Diehl B. Cerebellar, limbic, and midbrain volume alterations in sudden unexpected death in epilepsy. Epilepsia 2019; 60:718-729. [PMID: 30868560 DOI: 10.1111/epi.14689] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The processes underlying sudden unexpected death in epilepsy (SUDEP) remain elusive, but centrally mediated cardiovascular or respiratory collapse is suspected. Volume changes in brain areas mediating recovery from extreme cardiorespiratory challenges may indicate failure mechanisms and allow prospective identification of SUDEP risk. METHODS We retrospectively imaged SUDEP cases (n = 25), patients comparable for age, sex, epilepsy syndrome, localization, and disease duration who were high-risk (n = 25) or low-risk (n = 23), and age- and sex-matched healthy controls (n = 25) with identical high-resolution T1-weighted scans. Regional gray matter volume, determined by voxel-based morphometry, and segmentation-derived structure sizes were compared across groups, controlling for total intracranial volume, age, and sex. RESULTS Substantial bilateral gray matter loss appeared in SUDEP cases in the medial and lateral cerebellum. This was less prominent in high-risk subjects and absent in low-risk subjects. The periaqueductal gray, left posterior and medial thalamus, left hippocampus, and bilateral posterior cingulate also showed volume loss in SUDEP. High-risk subjects showed left thalamic volume reductions to a lesser extent. Bilateral amygdala, entorhinal, and parahippocampal volumes increased in SUDEP and high-risk patients, with the subcallosal cortex enlarged in SUDEP only. Disease duration correlated negatively with parahippocampal volume. Volumes of the bilateral anterior insula and midbrain in SUDEP cases were larger the closer to SUDEP from magnetic resonance imaging. SIGNIFICANCE SUDEP victims show significant tissue loss in areas essential for cardiorespiratory recovery and enhanced volumes in areas that trigger hypotension or impede respiratory patterning. Those changes may shed light on SUDEP pathogenesis and prospectively detect patterns identifying those at risk.
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Affiliation(s)
- Luke A Allen
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK.,Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Sjoerd B Vos
- Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK.,Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.,Wellcome/Engineering and Physical Sciences Research Council Centre for Interventional and Surgical Sciences, University College London, London, , UK.,Translational Imaging Group, Centre for Medical Image Computing, University College London, London, UK
| | - Rajesh Kumar
- Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.,Brain Research Institute, University of California, Los Angeles, Los Angeles, California.,Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.,Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.,Department of Bioengineering, University of California, Los Angeles, Los Angeles, California
| | - Jennifer A Ogren
- Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.,Department of Neurobiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Rebecca K Harper
- Department of Neurobiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Gavin P Winston
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK
| | - Simona Balestrini
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK
| | - Britta Wandschneider
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK
| | - Catherine A Scott
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Sebsatien Ourselin
- School of Biomedical Engineering and Imaging Sciences, St Thomas' Hospital, King's College London, London, UK
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK
| | - Samden D Lhatoo
- Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.,Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio.,Department of Neurology, University of Texas Health Sciences Center at Houston, United States
| | - Ronald M Harper
- Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.,Brain Research Institute, University of California, Los Angeles, Los Angeles, California.,Department of Neurobiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, University College London Institute of Neurology, London, UK.,Magnetic Resonance Imaging Unit, Epilepsy Society, London, UK.,Center for Sudden Unexpected Death in Epilepsy Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
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Allen LA, Harper RM, Lhatoo S, Lemieux L, Diehl B. Neuroimaging of Sudden Unexpected Death in Epilepsy (SUDEP): Insights From Structural and Resting-State Functional MRI Studies. Front Neurol 2019; 10:185. [PMID: 30891003 PMCID: PMC6413533 DOI: 10.3389/fneur.2019.00185] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/13/2019] [Indexed: 01/31/2023] Open
Abstract
The elusive nature of sudden unexpected death in epilepsy (SUDEP) has led to investigations of mechanisms and identification of biomarkers of this fatal scenario that constitutes the leading cause of premature death in epilepsy. In this short review, we compile evidence from structural and functional neuroimaging that demonstrates alterations to brain structures and networks involved in central autonomic and respiratory control in SUDEP and those at elevated risk. These findings suggest that compromised central control of vital regulatory processes may contribute to SUDEP. Both structural changes and dysfunctional interactions indicate potential mechanisms underlying the fatal event; contributions to individual risk prediction will require further study. The nature and sites of functional disruptions suggest potential non-invasive interventions to overcome failing processes.
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Affiliation(s)
- Luke A. Allen
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- Epilepsy Society MRI Unit, Chalfont St Peter, London, United Kingdom
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Ronald M. Harper
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
- Department of Neurobiology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA, United States
- Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, United States
| | - Samden Lhatoo
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Louis Lemieux
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- Epilepsy Society MRI Unit, Chalfont St Peter, London, United Kingdom
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, United Kingdom
- Epilepsy Society MRI Unit, Chalfont St Peter, London, United Kingdom
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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Nass RD, Motloch LJ, Paar V, Lichtenauer M, Baumann J, Zur B, Hoppe UC, Holdenrieder S, Elger CE, Surges R. Blood markers of cardiac stress after generalized convulsive seizures. Epilepsia 2019; 60:201-210. [PMID: 30645779 DOI: 10.1111/epi.14637] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Generalized convulsive seizures (GCS) are associated with high demands on the cardiovascular system, thereby facilitating cardiac complications. To investigate occurrence, influencing factors, and extent of cardiac stress or injury, the alterations and time course of the latest generation of cardiac blood markers were investigated after documented GCS. METHODS Adult patients with refractory epilepsy who underwent video-electroencephalography (EEG) monitoring along with simultaneous one-lead electrocardiography (ECG) recordings were included. Cardiac biomarkers (cardiac troponin I [cTNI]; high-sensitive troponin T [hsTNT]; N-terminal prohormone of brain natriuretic peptide [NT-proBNP]; copeptin; suppression of tumorigenicity-2 [SST-2]; growth differentiation factor 15, [GDF-15]; soluble urokinase plasminogen activator receptor [suPAR]; and heart-type fatty acid binding protein [HFABP]) and catecholamines were measured at inclusion and at different time points after GCS. Periictal cardiac properties were assessed by analyzing heart rate (HR), HR variability (HRV), and corrected QT intervals(QTc). RESULTS Thirty-six GCS (6 generalized-onset tonic-clonic seizures and 30 focal to bilateral tonic-clonic seizures) were recorded in 30 patients without a history of cardiac or renal disease. Postictal catecholamine levels were elevated more than twofold. A concomitant increase in HR and QTc, as well as a decrease in HRV, was observed. Elevations of cTNI and hsTNT were found in 3 of 30 patients (10%) and 6 of 23 patients (26%), respectively, which were associated with higher dopamine levels. Copeptin was increased considerably after most GCS, whereas SST-2, HFABP, and GDF-15 displayed only subtle variations, and suPAR was unaltered in the postictal period. Cardiac symptoms did not occur in any patient. SIGNIFICANCE The use of more sensitive biomarkers such as hsTNT suggests that signs of cardiac stress occur in about 25% of the patients with GCS without apparent clinical symptoms. SuPAR may indicate clinically relevant troponin elevations. Copeptin could help to diagnose GCS, but specificity needs to be tested.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Lukas J Motloch
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Vera Paar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Jan Baumann
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Berndt Zur
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn Medical Center, Bonn, Germany
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Stefan Holdenrieder
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn Medical Center, Bonn, Germany.,Institute for Laboratory Medicine, German Heart Center Munich, Technical University, Munich, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Section of Epileptology, Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
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Radhakrishnan DM, Ramanujam B, Srivastava P, Dash D, Tripathi M. Effect of providing sudden unexpected death in epilepsy (SUDEP) information to persons with epilepsy (PWE) and their caregivers-Experience from a tertiary care hospital. Acta Neurol Scand 2018; 138:417-424. [PMID: 29984404 DOI: 10.1111/ane.12994] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 06/19/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The primary objective of present study was to observe the effect of providing SUDEP (Sudden Unexpected Death in Epilepsy) information on drug adherence in persons with epilepsy (PWE). We also looked at impact of disclosing SUDEP information on patient's quality of life and mood. MATERIAL AND METHODS This prospective study had a pretest/post-test design. A total of 231 consecutive PWE (>15 years) were enrolled. Of these 121 PWE received information about SUDEP in addition to standard epilepsy care. One hundred and ten PWE (control group) received routine standard epilepsy care but did not receive SUDEP information. Follow up assessment was done at 6 months. The primary outcome was a change in drug adherence (measured by Modified Morisky Medication Adherence Scale, MMAS) in PWE following disclosure of SUDEP information. RESULTS After 6 months, 116 PWE in the SUDEP information group and 106 in control group were available for follow up. A non-significant higher adherence was observed in the SUDEP information group as compared to the control group (Mean MMAS change 0.51 ± 1.66 vs 0.25 ± 1.26, P value = 0.194). No significant change was perceived in patient's anxiety and depression levels or quality of life in either group. CONCLUSION The present study suggests that providing information on SUDEP to PWE and their caregivers may increase drug adherence without adverse effect on quality of life or mood. Well-designed studies with high methodological quality are required to determine the precise effect size associated with disclosure of SUDEP information on drug adherence in PWE.
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Affiliation(s)
| | - Bhargavi Ramanujam
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - Padma Srivastava
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - Deepa Dash
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - Manjari Tripathi
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
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Esmaeili B, Kaffashi F, Theeranaew W, Dabir A, Lhatoo SD, Loparo KA. Post-ictal Modulation of Baroreflex Sensitivity in Patients With Intractable Epilepsy. Front Neurol 2018; 9:793. [PMID: 30319527 PMCID: PMC6168624 DOI: 10.3389/fneur.2018.00793] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/03/2018] [Indexed: 11/20/2022] Open
Abstract
Objective: Seizure-related autonomic dysregulation occurs in epilepsy patients and may contribute to Sudden Unexpected Death in Epilepsy (SUDEP). We tested how different types of seizures affect baroreflex sensitivity (BRS) and heart rate variability (HRV). We hypothesized that BRS and HRV would be reduced after bilateral convulsive seizures (BCS). Methods: We recorded blood pressure (BP), electrocardiogram (ECG) and oxygen saturation continuously in patients (n = 18) with intractable epilepsy undergoing video-EEG monitoring. A total of 23 seizures, either focal seizures (FS, n = 14) or BCS (n = 9), were analyzed from these patients. We used 5 different HRV measurements in both the time and frequency domains to study HRV in pre- and post-ictal states. We used the average frequency domain gain, computed as the average of the magnitude ratio between the systolic BP (BPsys) and the RR-interval time series, in the low-frequency (LF) band as frequency domain index of BRS in addition to the instantaneous slope between systolic BP and RR-interval satisfying spontaneous BRS criteria as a time domain index of BRS. Results: Overall, the post-ictal modulation of HRV varied across the subjects but not specifically by the type of seizures. Comparing pre- to post-ictal epochs, the LF power of BRS decreased in 8 of 9 seizures for patients with BCS; whereas following 12 of 14 FS, BRS increased. Similarly, spontaneous BRS decreased following 7 of 9 BCS. The presence or absence of oxygen desaturation was not consistent with the changes in BRS following seizures, and the HRV does not appear to be correlated with the BRS changes. These data suggest that a transient decrease in BRS and temporary loss of cardiovascular homeostatic control can follow BCS but is unlikely following FS. Significance: These findings indicate significant post-ictal autonomic dysregulation in patients with epilepsy following BCS. Further, reduced BRS following BCS, if confirmed in future studies on SUDEP cases, may indicate one quantifiable risk marker of SUDEP.
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Affiliation(s)
- Behnaz Esmaeili
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Farhad Kaffashi
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Wanchat Theeranaew
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Aman Dabir
- Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Samden D Lhatoo
- Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Kenneth A Loparo
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
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Watkins L, Shankar R. Reducing the Risk of Sudden Unexpected Death in Epilepsy (SUDEP). Curr Treat Options Neurol 2018; 20:40. [DOI: 10.1007/s11940-018-0527-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gutiérrez-Maldonado E, Ledesma-Ramírez CI, Pliego-Carrillo AC, Reyes-Lagos JJ. Sign and magnitude scaling properties of heart rate fluctuations following vagus nerve stimulation in a patient with drug-resistant epilepsy. EPILEPSY & BEHAVIOR CASE REPORTS 2018; 10:78-81. [PMID: 30094179 PMCID: PMC6072651 DOI: 10.1016/j.ebcr.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 05/20/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023]
Abstract
Vagus nerve stimulation (VNS) therapy has been recently incorporated in Latin America as a treatment for drug-resistant epilepsy. In particular, it is known that linear analysis and fractal parameters of heart rate variability (HRV) are able to indirectly measure cardiac autonomic activity. This case report presents a 17-year-old female with drug-resistant epilepsy implanted with a VNS device. In order to explore cardiac autonomic changes due to VNS, linear and fractal HRV indices were calculated in the presence and absence of neurostimulation. Novel fractal scaling exponents from HRV analysis were obtained from this patient and from a healthy control subject. Our results indicate that fractal indices of HRV, such as short-term scaling parameters from magnitude and sign analyses seem to be sensitive to the presence or absence of VNS, being confirmed by linear classical methods. This study shows that VNS therapy increases the complexity of cardiac fluctuations in a patient with drug-resistant epilepsy, reflecting an augmented HRV non-linearity and a diminished anticorrelated pattern in heart rate fluctuations. A potential clinical use of these parameters includes the early identification of bradycardia, sudden unexpected death (SUDEP) risk and preoperative VNS approaches. Thus, the scaling and magnitude properties of HRV have potential importance as a non-invasive and easy method for adequate diagnostic/prognostic implications in epilepsy treatment.
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Affiliation(s)
| | | | | | - José Javier Reyes-Lagos
- Autonomous University of the State of Mexico (UAEMex), Faculty of Medicine, Toluca 50180, Mexico
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Nobis WP, Schuele S, Templer JW, Zhou G, Lane G, Rosenow JM, Zelano C. Amygdala-stimulation-induced apnea is attention and nasal-breathing dependent. Ann Neurol 2018; 83:460-471. [PMID: 29420859 DOI: 10.1002/ana.25178] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 11/16/2017] [Accepted: 12/11/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Evidence suggests that disordered breathing is critically involved in Sudden Unexpected Death in Epilepsy (SUDEP). To that end, evaluating structures that are activated by seizures and can activate brain regions that produce cardiorespiratory changes can further our understanding of the pathophysiology of SUDEP. Past preclinical studies have shown that electrical stimulation of the human amygdala induces apnea, suggesting a role for the amygdala in controlling respiration. In this study, we aimed to both confirm these findings in a larger group of patients with intractable temporal lobe epilepsy (TLE) and also further explore the anatomical and cognitive properties of this effect. METHODS Seven surgical TLE patients had depth electrodes implanted in the amygdala that were used to deliver electrical stimulation during functional mapping preceding resection. Real-time respiratory monitoring was performed in each patient to confirm apnea. RESULTS Our data confirm that amygdala stimulation reliably induces apnea (occurring in all 7 patients) and further suggest that apnea can be overcome by instructing the patient to inhale, and can be prevented entirely by breathing through the mouth before electrical stimulation. Finally, stimulation-induced apnea occurred only when stimulating the medial-most amygdalar contacts located in the central nucleus. INTERPRETATION These findings confirm a functional connection between the amygdala and respiratory control in humans. Moreover, they suggest specific amygdalar nuclei may be critical in mediating this effect and that attentional state is critical to apnea mediated by amygdala activation-perhaps alluding to future development of strategies for the prevention of SUDEP. Ann Neurol 2018;83:460-471.
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Affiliation(s)
- William P Nobis
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stephan Schuele
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jessica W Templer
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guangyu Zhou
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gregory Lane
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua M Rosenow
- Departments of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christina Zelano
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Watkins L, Shankar R, Sander JW. Identifying and mitigating Sudden Unexpected Death in Epilepsy (SUDEP) risk factors. Expert Rev Neurother 2018; 18:265-274. [PMID: 29425076 DOI: 10.1080/14737175.2018.1439738] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Sudden Unexpected Death in Epilepsy (SUDEP) is a significant cause of death for people with chronic epilepsy. Good practice guidance in the UK and the USA expect SUDEP to be discussed with the individual. The event rarity, methodological variance and lack of robust research into the pathological mechanisms, associated risk factors, and management strategies have created a challenge on how and what to discuss. There are some significant associations which allows for risk assessment and mitigation. Areas covered: The current understanding of static and modifiable risk factors for SUDEP and how to manage these more effectively are reviewed. Longitudinal risk may be assessed using standardised risk assessment tools which help in communicating risk. Technological advancement allows measurement of physiological parameters associated with seizures and risk of SUDEP using small wearable devices. Further evidence is needed to demonstrate such technologies are efficacious and safe. Expert commentary: Risk reduction should be an important part of epilepsy management and we suggest a Gold Standard of Care which healthcare professionals and services should aim for when approaching SUDEP risk management. A Minimum Standard of Care is also proposed that is practical to implement, that all people with epilepsy should expect to receive.
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Affiliation(s)
- Lance Watkins
- a Neath Port Talbot CLDT, Mental Health & Learning Disability Delivery Unit , Abertawe Bro Morgannwyg University Health Board , Morriston , Swansea
| | - Rohit Shankar
- b Department of Intellectual Disability Neuropsychiatry , Cornwall Partnership NHS Foundation Trust , Truro , UK.,c Exeter Medical School, Knowledge Spa , Royal Cornwall Hospital Truro , Cornwall , UK
| | - Josemir W Sander
- d UCL Institute of Neurology , NIHR University College London Hospitals Biomedical Research Centre , London , UK.,e Chalfont Centre for Epilepsy , Buckinghamshire , UK.,f Stichting Epilepsie Instellingen Nederland (SEIN) , Heemstede , Netherlands
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Functional Neuroplasticity in the Nucleus Tractus Solitarius and Increased Risk of Sudden Death in Mice with Acquired Temporal Lobe Epilepsy. eNeuro 2017; 4:eN-NWR-0319-17. [PMID: 29085908 PMCID: PMC5661358 DOI: 10.1523/eneuro.0319-17.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 12/23/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in individuals with refractory acquired epilepsy. Cardiorespiratory failure is the most likely cause in most cases, and central autonomic dysfunction has been implicated as a contributing factor to SUDEP. Neurons of the nucleus tractus solitarius (NTS) in the brainstem vagal complex receive and integrate vagally mediated information regarding cardiorespiratory and other autonomic functions, and GABAergic inhibitory NTS neurons play an essential role in modulating autonomic output. We assessed the activity of GABAergic NTS neurons as a function of epilepsy development in the pilocarpine-induced status epilepticus (SE) model of temporal lobe epilepsy (TLE). Compared with age-matched controls, mice that survived SE had significantly lower survival rates by 150 d post-SE. GABAergic NTS neurons from mice that survived SE displayed a glutamate-dependent increase in spontaneous action potential firing rate by 12 wks post-SE. Increased spontaneous EPSC frequency was also detected, but vagal afferent synaptic release properties were unaltered, suggesting that an increase in glutamate release from central neurons developed in the NTS after SE. Our results indicate that long-term changes in glutamate release and activity of GABAergic neurons emerge in the NTS in association with epileptogenesis. These changes might contribute to increased risk of cardiorespiratory dysfunction and sudden death in this model of TLE.
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Allen LA, Harper RM, Kumar R, Guye M, Ogren JA, Lhatoo SD, Lemieux L, Scott CA, Vos SB, Rani S, Diehl B. Dysfunctional Brain Networking among Autonomic Regulatory Structures in Temporal Lobe Epilepsy Patients at High Risk of Sudden Unexpected Death in Epilepsy. Front Neurol 2017; 8:544. [PMID: 29085330 PMCID: PMC5650686 DOI: 10.3389/fneur.2017.00544] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/27/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sudden unexpected death in epilepsy (SUDEP) is common among young people with epilepsy. Individuals who are at high risk of SUDEP exhibit regional brain structural and functional connectivity (FC) alterations compared with low-risk patients. However, less is known about network-based FC differences among critical cortical and subcortical autonomic regulatory brain structures in temporal lobe epilepsy (TLE) patients at high risk of SUDEP. METHODS 32 TLE patients were risk-stratified according to the following clinical criteria: age of epilepsy onset, duration of epilepsy, frequency of generalized tonic-clonic seizures, and presence of nocturnal seizures, resulting in 14 high-risk and 18 low-risk cases. Resting-state functional magnetic resonance imaging (rs-fMRI) signal time courses were extracted from 11 bilateral cortical and subcortical brain regions involved in autonomic and other regulatory processes. After computing all pairwise correlations, FC matrices were analyzed using the network-based statistic. FC strength among the 11 brain regions was compared between the high- and low-risk patients. Increases and decreases in FC were sought, using high-risk > low-risk and low-risk > high-risk contrasts (with covariates age, gender, lateralization of epilepsy, and presence of hippocampal sclerosis). RESULTS High-risk TLE patients showed a subnetwork with significantly reduced FC (t = 2.5, p = 0.029) involving the thalamus, brain stem, anterior cingulate, putamen and amygdala, and a second subnetwork with significantly elevated FC (t = 2.1, p = 0.031), which extended to medial/orbital frontal cortex, insula, hippocampus, amygdala, subcallosal cortex, brain stem, thalamus, caudate, and putamen. CONCLUSION TLE patients at high risk of SUDEP showed widespread FC differences between key autonomic regulatory brain regions compared to those at low risk. The altered FC revealed here may help to shed light on the functional correlates of autonomic disturbances in epilepsy and mechanisms involved in SUDEP. Furthermore, these findings represent possible objective biomarkers which could help to identify high-risk patients and enhance SUDEP risk stratification via the use of non-invasive neuroimaging, which would require validation in larger cohorts, with extension to patients with other epilepsies and subjects who succumb to SUDEP.
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Affiliation(s)
- Luke A Allen
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Ronald M Harper
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States
| | - Rajesh Kumar
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,UCLA Brain Research Institute, Los Angeles, CA, United States.,Department of Anaesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.,Department of Bioengineering, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Maxime Guye
- Aix Marseille University, CNRS, CRMBM UMR 7339, Marseille, France
| | - Jennifer A Ogren
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Samden D Lhatoo
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Epilepsy Centre, Neurological Institute, University Hospitals Case Medical Centre, Cleveland, OH, United States
| | - Louis Lemieux
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom
| | - Catherine A Scott
- Institute of Neurology, University College London, London, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Sjoerd B Vos
- Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Translational Imaging Group, University College London, London, United Kingdom
| | - Sandhya Rani
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States.,Epilepsy Centre, Neurological Institute, University Hospitals Case Medical Centre, Cleveland, OH, United States
| | - Beate Diehl
- Institute of Neurology, University College London, London, United Kingdom.,Epilepsy Society, Chalfont St. Peter, United Kingdom.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
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Nass RD, Meiling S, Andrié RP, Elger CE, Surges R. Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures. BMC Neurol 2017; 17:187. [PMID: 28927394 PMCID: PMC5605980 DOI: 10.1186/s12883-017-0965-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/11/2017] [Indexed: 11/15/2022] Open
Abstract
Background Generalized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS. Methods We retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures. Results A total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients. Conclusions Troponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Sina Meiling
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - René P Andrié
- Department of Medicine - Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany. .,Department of Neurology, Section of Epileptology, RWTH University Hospital Aachen, Aachen, Germany.
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Bauer PR, Thijs RD, Lamberts RJ, Velis DN, Visser GH, Tolner EA, Sander JW, Lopes da Silva FH, Kalitzin SN. Dynamics of convulsive seizure termination and postictal generalized EEG suppression. Brain 2017; 140:655-668. [PMID: 28073789 DOI: 10.1093/brain/aww322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/31/2016] [Indexed: 12/21/2022] Open
Abstract
It is not fully understood how seizures terminate and why some seizures are followed by a period of complete brain activity suppression, postictal generalized EEG suppression. This is clinically relevant as there is a potential association between postictal generalized EEG suppression, cardiorespiratory arrest and sudden death following a seizure. We combined human encephalographic seizure data with data of a computational model of seizures to elucidate the neuronal network dynamics underlying seizure termination and the postictal generalized EEG suppression state. A multi-unit computational neural mass model of epileptic seizure termination and postictal recovery was developed. The model provided three predictions that were validated in EEG recordings of 48 convulsive seizures from 48 subjects with refractory focal epilepsy (20 females, age range 15-61 years). The duration of ictal and postictal generalized EEG suppression periods in human EEG followed a gamma probability distribution indicative of a deterministic process (shape parameter 2.6 and 1.5, respectively) as predicted by the model. In the model and in humans, the time between two clonic bursts increased exponentially from the start of the clonic phase of the seizure. The terminal interclonic interval, calculated using the projected terminal value of the log-linear fit of the clonic frequency decrease was correlated with the presence and duration of postictal suppression. The projected terminal interclonic interval explained 41% of the variation in postictal generalized EEG suppression duration (P < 0.02). Conversely, postictal generalized EEG suppression duration explained 34% of the variation in the last interclonic interval duration. Our findings suggest that postictal generalized EEG suppression is a separate brain state and that seizure termination is a plastic and autonomous process, reflected in increased duration of interclonic intervals that determine the duration of postictal generalized EEG suppression.
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Affiliation(s)
- Prisca R Bauer
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Robert J Lamberts
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Demetrios N Velis
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Gerhard H Visser
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Else A Tolner
- Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Epilepsy Society, Chalfont St Peter SL9 0RJ, UK
| | - Fernando H Lopes da Silva
- Center of Neurosciences, Swammerdam Institute of Life Sciences, University of Amsterdam, P.O. Box 94215 1090 GE, The Netherlands.,Instituto Superior Técnico, University of Lisbon, 1049-001, Lisbon, Portugal
| | - Stiliyan N Kalitzin
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,Image Sciences Institute, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Nagae LM, Honce JM, Nyberg E, Ojemann S, Abosch A, Drees CN. Imaging of Laser Therapy in Epilepsy. J Neuroimaging 2017; 27:292-299. [PMID: 28370739 DOI: 10.1111/jon.12438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/23/2017] [Accepted: 02/25/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE MR-guided laser interstitial thermal therapy (MRgLITT) is an increasingly popular neuroablative method for the surgical treatment of epilepsy patients. This article intends to demonstrate the utility and pitfalls of imaging in the context of patient care with MRgLITT. MATERIAL AND METHODS A retrospective review of the medical records and imaging database with six illustrative cases selected to demonstrate the use of imaging throughout patient management with MRgLITT in diverse clinical situations and pathologies. A review of the knowledge in the literature was applied to the relevant points discussed. RESULTS Imaging findings were described in the setting of laser therapy in nonlesional epilepsy, mesial temporal sclerosis, dual pathology, periventricular nodular heterotopia, and schizencephaly. Discussion of imaging principles, potential pitfalls, as well as its use in the patient work-up and follow-up, is shown. CONCLUSIONS MRgLITT is an alternative minimally invasive therapy for refractory epilepsy, which is becoming widely sought for. Imaging plays a crucial role prior to, during, and after the procedure.
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Affiliation(s)
- Lidia M Nagae
- Department of Radiology, Neuroradiology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Justin M Honce
- Department of Radiology, Neuroradiology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Eric Nyberg
- Department of Radiology, Neuroradiology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado Denver School of Medicine, Aurora, CO
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado Denver School of Medicine, Aurora, CO
| | - Cornelia N Drees
- Department of Neurology, Epilepsy Section, University of Colorado Denver School of Medicine, Aurora, CO
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Hulbert J, Elger CE, Meyer R, Surges R. Antiepileptic Drugs Impair Shortening of Isolated Cardiomyocytes. Front Neurol 2017; 8:133. [PMID: 28421035 PMCID: PMC5376916 DOI: 10.3389/fneur.2017.00133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/21/2017] [Indexed: 11/28/2022] Open
Abstract
Background Most antiepileptic drugs (AEDs) inhibit seizure generation by acting on voltage-dependent ion channels. Voltage-dependent sodium and calcium channels are commonly expressed in brain and heart, suggesting that AEDs may have considerable cardiodepressive effects, thereby facilitating sudden cardiac death as a potential cause of sudden unexpected death in epilepsy. Here, we investigated the effects of carbamazepine (CBZ), lamotrigine (LTG), and levetiracetam (LEV) alone and in combination on the shortening properties of isolated ventricular cardiomyocytes of wild-type mice. Methods Properties of murine cardiomyocytes were determined by recording the sarcomere shortening with a video imaging system before, during, and after administration of AEDs in different concentrations and combinations. We assessed (i) the number of successful shortenings during continuous electrical stimulation (electromechanical coupling) and (ii) the shortening amplitude as well as other shortening-related properties upon repetitive electrical stimulation at 4 Hz. Data are given as mean ± SEM. Results At 100 μM, CBZ (10 cells), LTG (11 cells), and LEV (11 cells) alone had no effect on the electromechanical coupling but reversibly reduced shortening amplitudes by 15 ± 4, 24 ± 3, and 11 ± 3%, respectively. Increasing the LTG concentration to 250 (21 cells) and 500 μM (4 cells) reversibly inhibited the electromechanical coupling in 62 and 100% of the experiments. Importantly, simultaneous application of CBZ, LTG, and LEV at 100 μM also impaired the electromechanical coupling in 8 of 19 cardiomyocytes (42%) and reduced the shortening amplitude by 21 ± 4%. Conclusion Our data show that AEDs reversibly impair cardiac excitation and contraction. Importantly, the blocking effect on electromechanical coupling appears to be additive when different AEDs are simultaneously applied. The translational value of these experimental findings into clinical practice is limited. Our results, however, suggest that rationale AED therapy may be important with respect to cardiac side effects and potential facilitation of serious cardiac dysfunction especially when AEDs are used in combination or at very high doses.
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Affiliation(s)
- Johanna Hulbert
- Institute of Physiology II, University Hospital Bonn, Bonn, Germany
| | | | - Rainer Meyer
- Institute of Physiology II, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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44
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The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure 2017; 47:51-65. [DOI: 10.1016/j.seizure.2017.02.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022] Open
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Güngör M, Acar Arslan E, Tezer Filik Fİ, Saygi S. SUDEP: The First Case Series in Turkey. Noro Psikiyatr Ars 2017; 53:67-71. [PMID: 28360769 DOI: 10.5152/npa.2015.7553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 01/09/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Sudden unexpected death in epilepsy (SUDEP) is defined as the sudden, unexpected, witnessed or unwitnessed, non-traumatic, and non-drowning death of patients with epilepsy with or without evidence of a seizure, excluding documented status epilepticus, and in whom postmortem examinations do not reveal a toxicological or anatomic cause for death. In this study, data on patients who passed away under observation in the epilepsy clinic due to sudden, unexpected death have been compiled, and we also aim to emphasize the importance of SUDEP in Turkey. METHODS This study was performed with a total of nine cases. Data were obtained from hospital records, information given by the families of patients, the database of the General Directorate for Civil Services of the Ministry of Internal Affairs of Turkey, and from the Ankara Metropolitan Municipality Cemetery Information System. As the basis of classification and definition, the proposals suggested by Nashef et al., which were made to the International League Against Epilepsy (ILAE) in 2011, were taken into consideration. RESULTS Eight of the patients were classified as probable SUDEP and one of them as possible SUDEP; the mean age at SUDEP was 33 years, and the average follow-up period was 19.7 years. In these cases, except for known risk factors (generalized tonic-clonic seizures, nocturnal seizures, severe epilepsy, more frequent seizures, younger age at the onset of epilepsy, unwitnessed seizures, polytherapy, and mental handicap), a different risk factor was not identified. CONCLUSION This study is the first case series on SUDEP in Turkey. Postmortem studies are the most important shortcoming of the study. However, the importance of the topic is highlighted by presenting the available data. SUDEP deserves more attention during the daily practice of neurologists, pediatric neurologists, forensic physicians, and family physicians. If death is sudden and unexpected in a patient with epilepsy, SUDEP should be considered, regardless of the clear causes of death.
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Affiliation(s)
- Mesut Güngör
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Elif Acar Arslan
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
| | | | - Serap Saygi
- Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey
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Kang JY, Rabiei AH, Myint L, Nei M. Equivocal significance of post-ictal generalized EEG suppression as a marker of SUDEP risk. Seizure 2017; 48:28-32. [PMID: 28380395 DOI: 10.1016/j.seizure.2017.03.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/12/2017] [Accepted: 03/26/2017] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Our objective was to determine the significance of PGES as a possible EEG marker of increased risk for SUDEP and explore factors that influence PGES. METHODS We identified 17 patients who died due to definite or probable SUDEP and 52 living control patients with drug resistant focal epilepsy who underwent EEG monitoring and least one seizure recorded on EEG. We reviewed 305 seizures on EEG and when available, on video, for presence or absence of PGES, the duration of PGES immediately after seizure end, seizure type, state seizure occurred (sleep vs. wake), tonic duration and time from seizure onset to initial nursing intervention. We noted that majority (93% in SUDEP group and 83% living controls) with PGES had additional brief bursts of suppression. We measured the time from the end of seizure to end of last brief suppression to determine the time to final PGES. RESULTS SUDEP patients had statistically significant shorter PGES duration compared to living controls (unadjusted: -32.8s, 95%CI[-54.5, -11.2], adjusted: -39.5s, 95% CI[-59.4, -19.6]). SUDEP status was associated with longer time to final PGES compare to living controls, but this was not statistically significant. Earlier nursing intervention was associated with shorter seizure duration. PGES occurred only after GCS. Time to nursing intervention, tonic duration or state did not have a statistically significant effect on PGES. CONCLUSIONS PGES is an equivocal marker of increased SUDEP risk. Earlier nursing intervention is associated with shorter seizure duration and may play a role in reducing risk of SUDEP.
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Affiliation(s)
- Joon Y Kang
- Johns Hopkins School of Medicine, United States.
| | | | - Leslie Myint
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, United States
| | - Maromi Nei
- Thomas Jefferson University Hospital, United States
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Abstract
The heart and brain are constantly interacting under normal physiological conditions. This interaction is under the control of the autonomic nervous system with parasympathetic and sympathetic nerve fibers including the participating brain structures. Pathological conditions, such as epilepsy and ischemic cerebral stroke influence heart function, especially the frequency and may result in severe arrhythmia. An asymmetric influence of the left and right brain hemispheres on the heart rate is still under debate. Conversely, the influence of the heart in cases of acute cardiac arrest on brain function is equally relevant and a common clinical problem after resuscitation. We review the damaging cascade of global cerebral hypoxia and the value of different diagnostic procedures as well as the ethical problem of the point in time of termination of consciousness and the instruments for estimating the prognosis.
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Abstract
OPINION STATEMENT Epilepsy is a chronic neurological disorder frequently requiring lifelong treatment. In 70% of epilepsy patients, seizures are well controlled by antiepileptic medications. About 30% of epilepsy patients remain refractory to medical treatments and may need surgical interventions for better seizure control. Unfortunately and not infrequently, surgical intervention is not feasible due to various reasons such as multiple seizure foci, not resectable focus because of eloquent cortex location, or inability to tolerate surgery due to ongoing concomitant medical conditions. Neurostimulation devices have provided possible seizure control for refractory epilepsy patients who are not candidates for surgical intervention. Among them, vagal nerve stimulation (VNS) has been the oldest, in use since 1997. VNS was followed by responsive nerve stimulation (RNS) after obtaining FDA approval in 2013. Deep brain stimulation (DBS) has not yet met approval in the USA, but has been in clinical practice in Europe since 2010. Neurostimulation devices vary in how they are inserted and their mechanisms of action. VNS has been easily accepted by patients since it is placed extracranially. By contrast, DBS and RNS require invasive procedures for intracranial implantation. As use of these devices will continue to increase in the foreseeable future, we aimed to contribute to the foundation for new research to expand on current knowledge and practice by reviewing the current status of the literature.
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Abstract
Voltage-gated sodium channels are protein complexes comprised of one pore forming α subunit and two, non-pore forming, β subunits. The voltage-gated sodium channel β subunits were originally identified to function as auxiliary subunits, which modulate the gating, kinetics, and localization of the ion channel pore. Since that time, the five β subunits have been shown to play crucial roles as multifunctional signaling molecules involved in cell adhesion, cell migration, neuronal pathfinding, fasciculation, and neurite outgrowth. Here, we provide an overview of the evidence implicating the β subunits in their conducting and non-conducting roles. Mutations in the β subunit genes (SCN1B-SCN4B) have been linked to a variety of diseases. These include cancer, epilepsy, cardiac arrhythmias, sudden infant death syndrome/sudden unexpected death in epilepsy, neuropathic pain, and multiple neurodegenerative disorders. β subunits thus provide novel therapeutic targets for future drug discovery.
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Affiliation(s)
- Alexandra A Bouza
- Department of Pharmacology, University of Michigan Medical School, 2200 MSRBIII, 1150 W. Medical Center Dr., Ann Arbor, MI, 48109-5632, USA
| | - Lori L Isom
- Department of Pharmacology, University of Michigan Medical School, 2301 MSRB III, 1150 W. Medical Center Dr., Ann Arbor, MI, 48109-5632, USA.
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Aurlien D, Gjerstad L, Taubøll E. The role of antiepileptic drugs in sudden unexpected death in epilepsy. Seizure 2016; 43:56-60. [PMID: 27886630 DOI: 10.1016/j.seizure.2016.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/26/2016] [Accepted: 11/05/2016] [Indexed: 01/30/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) primarily affects young adults and is the leading cause of death related directly to seizures. High frequency of generalized tonic-clonic seizures is the most important risk factor, and effective seizure protection is probably the most important measure to prevent these tragic deaths. For several years a potential role of antiepileptic drugs (AEDs) has been discussed, but at present there is wide agreement that choice of AED therapy does not influence the risk. However, although it is well known that the efficacy and safety profiles of AEDs may differ significantly when used in the treatment of genetic epilepsy compared to symptomatic or cryptogenic epilepsy, this has generally been overlooked in epidemiologic studies of possible relationships between AEDs and SUDEP. Consequently important information about drug safety may have been lost. This review challenges the current view that no AED can increase the risk of SUDEP.
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Affiliation(s)
- Dag Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
| | - Leif Gjerstad
- Department of Neurology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
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