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Follmann R, Jaswal T, Jacob G, de Oliveira JF, Herbert CB, Macau EEN, Rosa E. Temperature effects on neuronal synchronization in seizures. CHAOS (WOODBURY, N.Y.) 2024; 34:083141. [PMID: 39191247 DOI: 10.1063/5.0219836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/08/2024] [Indexed: 08/29/2024]
Abstract
We present a computational model of networked neurons developed to study the effect of temperature on neuronal synchronization in the brain in association with seizures. The network consists of a set of chaotic bursting neurons surrounding a core tonic neuron in a square lattice with periodic boundary conditions. Each neuron is reciprocally coupled to its four nearest neighbors via temperature dependent gap junctions. Incorporating temperature in the gap junctions makes the coupling stronger when temperature rises, resulting in higher likelihood for synchrony in the network. Raising the temperature eventually makes the network elicit waves of synchronization in circular ripples that propagate from the center outwardly. We suggest this process as a possible underlying mechanism for seizures induced by elevated brain temperatures.
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Affiliation(s)
- Rosangela Follmann
- School of Information Technology, Illinois State University, Normal, Illinois 61790, USA
| | - Twinkle Jaswal
- School of Information Technology, Illinois State University, Normal, Illinois 61790, USA
| | - George Jacob
- School of Information Technology, Illinois State University, Normal, Illinois 61790, USA
| | | | - Carter B Herbert
- Department of Physics, Illinois State University, Normal, Illinois 61790, USA
| | - Elbert E N Macau
- Federal University of São Paulo (UNIFESP), São José dos Campos, São Paulo, 12247-014 Brazil
| | - Epaminondas Rosa
- Department of Physics, Illinois State University, Normal, Illinois 61790, USA
- School of Biological Sciences, Illinois State University, Normal, Illinois 61790, USA
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2
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Gould L, Reid CA, Rodriguez AJ, Devinsky O. Video Analyses of Sudden Unexplained Deaths in Toddlers. Neurology 2024; 102:e208038. [PMID: 38175965 PMCID: PMC11097764 DOI: 10.1212/wnl.0000000000208038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES More than 2,900 US children aged younger than 4 years die from unknown causes each year, accounting for more than 219,000 life years lost annually. They are mostly sleep-related and unwitnessed with unremarkable autopsies, limiting our understanding of death mechanisms. We sought to understand potential mechanisms of death by evaluating videos of sudden deaths in toddlers. METHODS In our registry of 301 sudden unexplained child deaths, a series of 7 consecutively enrolled cases with home video recordings of the child's last sleep period were independently assessed by 8 physicians for video quality, movement, and sound. RESULTS Four boys and 3 girls (13-27 months at death) with terminal videos shared similar demographic features to the 293 other registry cases without video recordings. Five video recordings were continuous and 2 were triggered by sound or motion. Two lacked audio. All continuous recordings included a terminal convulsive event lasting 8-50 seconds; 4 children survived for >2.5 minutes postconvulsion. Among discontinuous videos, time lapses limited review; 1 suggested a convulsive event. Six were prone with face down, and 1 had autopsy evidence of airway obstruction. Primary cardiac arrhythmias were not supported; all 7 children had normal cardiac pathology and whole-exome sequencing identified no known cardiac disease variants. DISCUSSION Audio-visual recordings in 7 toddlers with unexplained sudden deaths strongly implicate that deaths were related to convulsive seizures, suggesting that many unexplained sleep-related deaths may result from seizures.
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Affiliation(s)
- Laura Gould
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Codi-Ann Reid
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Alcibiades J Rodriguez
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Orrin Devinsky
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
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3
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Zhai Y, Cheng Y, Yuan Y, Meng X, Li Y, Wang Y, Ren T, Li S, Sun H. Increased thrombospondin-1 levels contribute to epileptic susceptibility in neonatal hyperthermia without seizures via altered synaptogenesis. Cell Death Discov 2024; 10:73. [PMID: 38346981 PMCID: PMC10861539 DOI: 10.1038/s41420-024-01837-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
Childhood febrile seizures (FS) represent one of the most common types of seizures and may lead to severe neurological damage and an increased risk of epilepsy. However, most children with fevers do not show clinical manifestations of convulsions, and the consequences of hyperthermia without seizures remain elusive. This study focused on hyperthermia not reaching the individual's seizure threshold (sub-FS stimulus). Changes in thrombospondin-1 (TSP-1) levels, synapses, seizure susceptibility, and seizure severity in subsequent FS were investigated in rats exposed to sub-FS stimuli. Pharmacological and genetic interventions were used to explore the role of TSP-1 in sub-FS-induced effects. We found that after sub-FS stimuli, the levels of TSP-1 and synapses, especially excitatory synapses, were concomitantly increased, with increased epilepsy and FS susceptibility. Moreover, more severe neuronal damage was found in subsequent FS. These changes were temperature dependent. Reducing TSP-1 levels by genetic intervention or inhibiting the activation of transforming growth factor-β1 (TGF-β1) by Leu-Ser-Lys-Leu (LSKL) led to lower synapse/excitatory synapse levels, decreased epileptic susceptibility, and attenuated neuronal injury after FS stimuli. Our study confirmed that even without seizures, hyperthermia may promote synaptogenesis, increase epileptic and FS susceptibility, and lead to more severe neuronal damage by subsequent FS. Inhibition of the TSP-1/TGF-β1 pathway may be a new therapeutic target to prevent detrimental sub-FS sequelae.
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Affiliation(s)
- Yujie Zhai
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Yao Cheng
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Yi Yuan
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Xianfeng Meng
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Yang Li
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Yan Wang
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Tianpu Ren
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China
| | - Shucui Li
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China.
| | - Hongliu Sun
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, 264003, China.
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4
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Wojcik MH, Krous HF, Goldstein RD. Sudden Unexplained Death in Childhood: Current Understanding. Pediatr Emerg Care 2023; 39:979-983. [PMID: 38019718 DOI: 10.1097/pec.0000000000003074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
ABSTRACT Sudden unexplained death in childhood is a term that encompasses apparently natural deaths in children aged older than 1 year with no discernible cause despite a thorough assessment. Definitive underlying causes vary but most cases remain largely unexplained. Research has furthered the view that sudden unexplained death in childhood is not an accident, but rather a sentinel medical event for which a thorough postmortem investigation is indicated. Emerging evidence in genetics, neurology, and neuropathology point to heterogeneous causes that in some cases share features of recognized diseases.
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Affiliation(s)
| | - Henry F Krous
- Professor, University of California at San Diego and Rady Children's Hospital, San Diego, CA
| | - Richard D Goldstein
- Associate Professor, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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5
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Gould L, Delavale V, Plovnick C, Wisniewski T, Devinsky O. Are brief febrile seizures benign? A systematic review and narrative synthesis. Epilepsia 2023; 64:2539-2549. [PMID: 37466925 DOI: 10.1111/epi.17720] [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: 03/16/2023] [Revised: 07/15/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
Febrile seizures affect 2%-5% of U.S. children and are considered benign although associated with an increased risk of epilepsy and, rarely, with sudden unexplained death. We compared rates of mortality, neurodevelopmental disorders, and neuropathology in young children with simple and complex febrile seizures to healthy controls. We systematically reviewed studies of 3- to 72-month-old children with simple or complex febrile seizures ≤30 min. We searched studies with outcome measures on mortality, neurodevelopment, or neuropathology through July 18, 2022. Bias risk was assessed per study design. Each outcome measure was stratified by study design. PROSPERO registration is CRD42022361645. Twenty-six studies met criteria reporting mortality (11), neurodevelopment (11), and neuropathology (13), including 2665 children with febrile seizures and 1206 seizure-free controls. Study designs varied: 15 cohort, 2 cross-sectional, 3 case-control, 5 series, and 1 case report. Mortality outcomes showed stark contrasts. Six cohort studies following children after febrile seizure (n = 1348) reported no deaths, whereas four child death series and 1 case report identified 24.1% (108/449) deaths associated with simple (n = 104) and complex (n = 3) febrile seizures ≤30 min. Minor hippocampal histopathological anomalies were common in sudden deaths with or without febrile seizure history. Most electroencephalography (EEG) studies were normal. Neuroimaging studies suggested increased right hippocampal volumes. When present, neurodevelopmental problems usually preexisted febrile-seizure onset. Risk bias was medium or high in 95% (18/19) of cohort and case-control studies vs medium to low across remaining study designs. Research on outcomes after simple or brief complex febrile seizures is limited. Cohort studies suffered from inadequate sample size, bias risk, and limited follow-up durations to make valid conclusions on mortality, neurodevelopment, and neuropathology. Sudden death registries, focused on a very small percentage of all cases, strongly suggest that simple febrile seizures are associated with increased mortality. Although most children with febrile seizures have favorable outcomes, longer-term prospective studies are needed.
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Affiliation(s)
- Laura Gould
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Victoria Delavale
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Caitlin Plovnick
- Health Sciences Library, NYU Grossman School of Medicine, New York, New York, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Pathology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Center for Cognitive Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Psychiatry, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Health, New York, New York, USA
- Department of Neurology, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
- Department of Psychiatry, NYU Langone Health and NYU Grossman School of Medicine, New York, New York, USA
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6
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Cheng Y, Zhai Y, Yuan Y, Li H, Zhao W, Fan Z, Zhou L, Gao X, Zhan Y, Sun H. Xenon inhalation attenuates neuronal injury and prevents epilepsy in febrile seizure Sprague-Dawley pups. Front Cell Neurosci 2023; 17:1155303. [PMID: 37645594 PMCID: PMC10461106 DOI: 10.3389/fncel.2023.1155303] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Background Febrile seizures (FS) usually occur in childhood and may cause irreversible neuronal damage, cognitive functional defects, and an increase in the risk of epilepsy later in life. Anti-epileptic drugs (AEDs), currently used to treat FS in children, can relieve seizures. However, their effects in preventing the risk of developing epilepsy in later life are unsatisfactory. Moreover, AEDs may damage child brain development. Here, we evaluated the efficiency of xenon in treating prolonged FS (PFS) and preventing epilepsy in Sprague-Dawley pups. Methods Prolonged FS was induced by hyperthermic treatment. After 90 min of PFS, the pups in the xenon treatment group were immediately treated with 70% xenon/21% oxygen/9% nitrogen for 60 min. The levels of glutamate, mitochondrial oxidative stress, mitophagy, and neuronal injury, seizures, learning, and memory functions were measured at specific time points. Results Neonatal period PFS led to spontaneous seizure, learning and memory dysfunction, accompanied by increased levels of glutamate, mitochondrial oxidative stress, mitophagy, and neuronal injury. Xenon treatment alleviated the changes caused by PFS and reduced the risk of PFS developing into epilepsy later. Conclusion Our results suggest that xenon inhalation could be a potential therapeutic strategy to attenuate neuronal injury and prevent epilepsy in patients with FS.
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Affiliation(s)
- Yao Cheng
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Yujie Zhai
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Yi Yuan
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Hao Li
- School of Medical Imaging, Binzhou Medical University, Yantai, China
| | - Wenke Zhao
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Zhenhai Fan
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Ling Zhou
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Xue Gao
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
| | - Yan Zhan
- Department of Neurology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, China
| | - Hongliu Sun
- School of Pharmaceutical Sciences, Binzhou Medical University, Yantai, China
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Bauer J, Devinsky O, Rothermel M, Koch H. Autonomic dysfunction in epilepsy mouse models with implications for SUDEP research. Front Neurol 2023; 13:1040648. [PMID: 36686527 PMCID: PMC9853197 DOI: 10.3389/fneur.2022.1040648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023] Open
Abstract
Epilepsy has a high prevalence and can severely impair quality of life and increase the risk of premature death. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in drug-resistant epilepsy and most often results from respiratory and cardiac impairments due to brainstem dysfunction. Epileptic activity can spread widely, influencing neuronal activity in regions outside the epileptic network. The brainstem controls cardiorespiratory activity and arousal and reciprocally connects to cortical, diencephalic, and spinal cord areas. Epileptic activity can propagate trans-synaptically or via spreading depression (SD) to alter brainstem functions and cause cardiorespiratory dysfunction. The mechanisms by which seizures propagate to or otherwise impair brainstem function and trigger the cascading effects that cause SUDEP are poorly understood. We review insights from mouse models combined with new techniques to understand the pathophysiology of epilepsy and SUDEP. These techniques include in vivo, ex vivo, invasive and non-invasive methods in anesthetized and awake mice. Optogenetics combined with electrophysiological and optical manipulation and recording methods offer unique opportunities to study neuronal mechanisms under normal conditions, during and after non-fatal seizures, and in SUDEP. These combined approaches can advance our understanding of brainstem pathophysiology associated with seizures and SUDEP and may suggest strategies to prevent SUDEP.
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Affiliation(s)
- Jennifer Bauer
- Department of Epileptology and Neurology, RWTH Aachen University, Aachen, Germany,Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Orrin Devinsky
- Departments of Neurology, Neurosurgery and Psychiatry, NYU Langone School of Medicine, New York, NY, United States
| | - Markus Rothermel
- Institute for Physiology and Cell Biology, University of Veterinary Medicine Hannover, Foundation, Hannover, Germany
| | - Henner Koch
- Department of Epileptology and Neurology, RWTH Aachen University, Aachen, Germany,*Correspondence: Henner Koch ✉
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Leitner DF, William C, Faustin A, Askenazi M, Kanshin E, Snuderl M, McGuone D, Wisniewski T, Ueberheide B, Gould L, Devinsky O. Proteomic differences in hippocampus and cortex of sudden unexplained death in childhood. Acta Neuropathol 2022; 143:585-599. [PMID: 35333953 PMCID: PMC8953962 DOI: 10.1007/s00401-022-02414-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 11/01/2022]
Abstract
Sudden unexplained death in childhood (SUDC) is death of a child over 1 year of age that is unexplained after review of clinical history, circumstances of death, and complete autopsy with ancillary testing. Multiple etiologies may cause SUDC. SUDC and sudden unexpected death in epilepsy (SUDEP) share clinical and pathological features, suggesting some similarities in mechanism of death and possible abnormalities in hippocampus and cortex. To identify molecular signaling pathways, we performed label-free quantitative mass spectrometry on microdissected frontal cortex, hippocampal dentate gyrus (DG), and cornu ammonis (CA1-3) in SUDC (n = 19) and pediatric control cases (n = 19) with an explained cause of death. At a 5% false discovery rate (FDR), we found differential expression of 660 proteins in frontal cortex, 170 in DG, and 57 in CA1-3. Pathway analysis of altered proteins identified top signaling pathways associated with activated oxidative phosphorylation (p = 6.3 × 10-15, z = 4.08) and inhibited EIF2 signaling (p = 2.0 × 10-21, z = - 2.56) in frontal cortex, and activated acute phase response in DG (p = 8.5 × 10-6, z = 2.65) and CA1-3 (p = 4.7 × 10-6, z = 2.00). Weighted gene correlation network analysis (WGCNA) of clinical history indicated that SUDC-positive post-mortem virology (n = 4/17) had the most significant module in each brain region, with the top most significant associated with decreased mRNA metabolic processes (p = 2.8 × 10-5) in frontal cortex. Additional modules were associated with clinical history, including fever within 24 h of death (top: increased mitochondrial fission in DG, p = 1.8 × 10-3) and febrile seizure history (top: decreased small molecule metabolic processes in frontal cortex, p = 8.8 × 10-5) in all brain regions, neuropathological hippocampal findings in the DG (top: decreased focal adhesion, p = 1.9 × 10-3). Overall, cortical and hippocampal protein changes were present in SUDC cases and some correlated with clinical features. Our studies support that proteomic studies of SUDC cohorts can advance our understanding of the pathogenesis of these tragedies and may inform the development of preventive strategies.
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De novo mutations in childhood cases of sudden unexplained death that disrupt intracellular Ca2+ regulation. Proc Natl Acad Sci U S A 2021; 118:2115140118. [PMID: 34930847 PMCID: PMC8719874 DOI: 10.1073/pnas.2115140118] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/04/2023] Open
Abstract
Approximately 400 United States children 1 y of age and older die suddenly from unexplained causes annually. We studied whole-exome sequence data from 124 “trios” (decedent child and living parents) to identify genetic risk factors. Nonsynonymous mutations, mostly de novo (present in child but absent in both biological parents), were highly enriched in genes associated with cardiac and seizure disorders relative to controls, and contributed to 9% of deaths. We found significant overtransmission of loss-of-function or pathogenic missense variants in cardiac and seizure disorder genes. Most pathogenic variants were de novo in origin, highlighting the importance of trio studies. Many of these pathogenic de novo mutations altered a protein network regulating calcium-related excitability at submembrane junctions in cardiomyocytes and neurons. Sudden unexplained death in childhood (SUDC) is an understudied problem. Whole-exome sequence data from 124 “trios” (decedent child, living parents) was used to test for excessive de novo mutations (DNMs) in genes involved in cardiac arrhythmias, epilepsy, and other disorders. Among decedents, nonsynonymous DNMs were enriched in genes associated with cardiac and seizure disorders relative to controls (odds ratio = 9.76, P = 2.15 × 10−4). We also found evidence for overtransmission of loss-of-function (LoF) or previously reported pathogenic variants in these same genes from heterozygous carrier parents (11 of 14 transmitted, P = 0.03). We identified a total of 11 SUDC proband genotypes (7 de novo, 1 transmitted parental mosaic, 2 transmitted parental heterozygous, and 1 compound heterozygous) as pathogenic and likely contributory to death, a genetic finding in 8.9% of our cohort. Two genes had recurrent missense DNMs, RYR2 and CACNA1C. Both RYR2 mutations are pathogenic (P = 1.7 × 10−7) and were previously studied in mouse models. Both CACNA1C mutations lie within a 104-nt exon (P = 1.0 × 10−7) and result in slowed L-type calcium channel inactivation and lower current density. In total, six pathogenic DNMs can alter calcium-related regulation of cardiomyocyte and neuronal excitability at a submembrane junction, suggesting a pathway conferring susceptibility to sudden death. There was a trend for excess LoF mutations in LoF intolerant genes, where ≥1 nonhealthy sample in denovo-db has a similar variant (odds ratio = 6.73, P = 0.02); additional uncharacterized genetic causes of sudden death in children might be discovered with larger cohorts.
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10
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Leitner DF, McGuone D, William C, Faustin A, Askenazi M, Snuderl M, Guzzetta M, Jarrell HS, Maloney K, Reichard R, Smith C, Weedn V, Wisniewski T, Gould L, Devinsky O. Blinded review of hippocampal neuropathology in sudden unexplained death in childhood reveals inconsistent observations and similarities to explained paediatric deaths. Neuropathol Appl Neurobiol 2021; 48:e12746. [PMID: 34164845 DOI: 10.1111/nan.12746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/19/2021] [Indexed: 12/29/2022]
Abstract
AIMS Hippocampal findings are implicated in the pathogenesis of sudden unexplained death in childhood (SUDC), although some studies have identified similar findings in sudden explained death in childhood (SEDC) cases. We blindly reviewed hippocampal histology in SUDC and SEDC controls. METHODS Hippocampal haematoxylin and eosin (H&E) slides (n = 67; 36 SUDC, 31 controls) from clinical and forensic collaborators were evaluated by nine blinded reviewers: three board-certified forensic pathologists, three neuropathologists and three dual-certified neuropathologists/forensic pathologists. RESULTS Among nine reviewers, about 50% of hippocampal sections were rated as abnormal (52.5% SUDC, 53.0% controls), with no difference by cause of death (COD) (p = 0.16) or febrile seizure history (p = 0.90). There was little agreement among nine reviewers on whether a slide was within normal range (Fleiss' κ = 0.014, p = 0.47). Within reviewer groups, there were no findings more frequent in SUDC compared with controls, with variability in pyramidal neuron and dentate gyrus findings. Across reviewer groups, there was concordance for bilamination and granule cell loss. Neither SUDC (51.2%) nor control (55.9%) slides were considered contributory to determining COD (p = 0.41). CONCLUSIONS The lack of an association of hippocampal findings in SUDC and controls, as well as inconsistency of observations by multiple blinded reviewers, indicates discrepancy with previous studies and an inability to reliably identify hippocampal maldevelopment associated with sudden death (HMASD). These findings underscore a need for larger studies to standardise evaluation of hippocampal findings, identifying the range of normal variation and changes unrelated to SUDC or febrile seizures. Molecular studies may help identify novel immunohistological markers that inform on COD.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA
| | - Christopher William
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Arline Faustin
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
| | | | - Matija Snuderl
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Melissa Guzzetta
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Heather S Jarrell
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,New Mexico Office of the Medical Investigator, Albuquerque, New Mexico, USA
| | - Katherine Maloney
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,New York Department of Health, Erie County Medical Examiner's Office, Buffalo, New York, USA
| | - Ross Reichard
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin Smith
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Academic Department of Neuropathology, University of Edinburgh, Edinburgh, UK
| | - Victor Weedn
- SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Maryland Department of Health, Office of the Chief Medical Examiner, Baltimore, Maryland, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,SUDC Registry and Research Collaborative (SUDCRRC) Study Group, Roseland, New Jersey, USA.,Department of Pathology, NYU Langone Health and School of Medicine, New York, New York, USA.,Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Psychiatry, NYU Langone Health and School of Medicine, New York, New York, USA
| | - Laura Gould
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Sudden Unexplained Death in Childhood Foundation, Roseland, New Jersey, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Langone Health and School of Medicine, New York, New York, USA.,Department of Neurology, NYU Langone Health and School of Medicine, New York, New York, USA
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11
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Pires G, Leitner D, Drummond E, Kanshin E, Nayak S, Askenazi M, Faustin A, Friedman D, Debure L, Ueberheide B, Wisniewski T, Devinsky O. Proteomic differences in the hippocampus and cortex of epilepsy brain tissue. Brain Commun 2021; 3:fcab021. [PMID: 34159317 DOI: 10.1093/braincomms/fcab021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/22/2022] Open
Abstract
Epilepsy is a common neurological disorder affecting over 70 million people worldwide, with a high rate of pharmaco-resistance, diverse comorbidities including progressive cognitive and behavioural disorders, and increased mortality from direct (e.g. sudden unexpected death in epilepsy, accidents, drowning) or indirect effects of seizures and therapies. Extensive research with animal models and human studies provides limited insights into the mechanisms underlying seizures and epileptogenesis, and these have not translated into significant reductions in pharmaco-resistance, morbidities or mortality. To help define changes in molecular signalling networks associated with seizures in epilepsy with a broad range of aetiologies, we examined the proteome of brain samples from epilepsy and control cases. Label-free quantitative mass spectrometry was performed on the hippocampal cornu ammonis 1-3 region (CA1-3), frontal cortex and dentate gyrus microdissected from epilepsy and control cases (n = 14/group). Epilepsy cases had significant differences in the expression of 777 proteins in the hippocampal CA1 - 3 region, 296 proteins in the frontal cortex and 49 proteins in the dentate gyrus in comparison to control cases. Network analysis showed that proteins involved in protein synthesis, mitochondrial function, G-protein signalling and synaptic plasticity were particularly altered in epilepsy. While protein differences were most pronounced in the hippocampus, similar changes were observed in other brain regions indicating broad proteomic abnormalities in epilepsy. Among the most significantly altered proteins, G-protein subunit beta 1 (GNB1) was one of the most significantly decreased proteins in epilepsy in all regions studied, highlighting the importance of G-protein subunit signalling and G-protein-coupled receptors in epilepsy. Our results provide insights into common molecular mechanisms underlying epilepsy across various aetiologies, which may allow for novel targeted therapeutic strategies.
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Affiliation(s)
- Geoffrey Pires
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, NY, USA.,Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Alzheimer's and Prion Diseases Team, Paris Brain Institute, CNRS, UMR 7225, INSERM 1127, Sorbonne University UM75, Paris, France
| | - Dominique Leitner
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, NY, USA
| | - Eleanor Drummond
- Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Faculty of Medicine and Health, Brain and Mind Centre and School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Evgeny Kanshin
- Proteomics Laboratory, Division of Advanced Research Technologies, New York University Grossman School of Medicine, New York, NY, USA
| | - Shruti Nayak
- Proteomics Laboratory, Division of Advanced Research Technologies, New York University Grossman School of Medicine, New York, NY, USA
| | - Manor Askenazi
- Biomedical Hosting LLC, USA.,Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, USA
| | - Arline Faustin
- Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, NY, USA
| | - Ludovic Debure
- Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Beatrix Ueberheide
- Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Proteomics Laboratory, Division of Advanced Research Technologies, New York University Grossman School of Medicine, New York, NY, USA.,Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, USA
| | - Thomas Wisniewski
- Department of Neurology, Center for Cognitive Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA.,Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, NY, USA
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12
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Harowitz J, Crandall L, McGuone D, Devinsky O. Seizure-related deaths in children: The expanding spectrum. Epilepsia 2021; 62:570-582. [PMID: 33586153 PMCID: PMC7986159 DOI: 10.1111/epi.16833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/26/2022]
Abstract
Although seizures are common in children, they are often overlooked as a potential cause of death. Febrile and nonfebrile seizures can be fatal in children with or without an epilepsy diagnosis and may go unrecognized by parents or physicians. Sudden unexpected infant deaths, sudden unexplained death in childhood, and sudden unexpected death in epilepsy share clinical, neuropathological, and genetic features, including male predominance, unwitnessed deaths, death during sleep, discovery in the prone position, hippocampal abnormalities, and variants in genes regulating cardiac and neuronal excitability. Additionally, epidemiological studies reveal that miscarriages are more common among individuals with a personal or family history of epilepsy, suggesting that some fetal losses may result from epileptic factors. The spectrum of seizure-related deaths in pediatrics is wide and underappreciated; accurately estimating this mortality and understanding its mechanism in children is critical to developing effective education and interventions to prevent these tragedies.
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Affiliation(s)
- Jenna Harowitz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA.,SUDC Foundation, Herndon, Virginia, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA
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13
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Kurlemann G. Fieberkrämpfe. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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McGuone D, Crandall LG, Devinsky O. Sudden Unexplained Death in Childhood: A Neuropathology Review. Front Neurol 2020; 11:582051. [PMID: 33178125 PMCID: PMC7596260 DOI: 10.3389/fneur.2020.582051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Sudden Unexplained Death in Childhood (SUDC) is the unexpected death of a child over age 12 months that remains unexplained after a thorough case investigation, including review of the child's medical history, circumstances of death, a complete autopsy and ancillary testing (1). First defined in 2005, SUDC cases are more often male, with death occurring during a sleep period, being found prone, peak winter incidence, associated with febrile seizure history in ~28% of cases and mild pathologic changes insufficient to explain the death (1, 2). There has been little progress in understanding the causes of SUDC and no progress in prevention. Despite reductions in sudden unexpected infant death (SUID) and other causes of mortality in childhood, the rate of SUDC has increased during the past two decades (3-5). In Ireland, SUID deaths were cut in half from 1994 to 2008 while SUDC deaths more than doubled (4). Surveillance issues, including lack of standardized certification practices, affect our understanding of the true magnitude of unexplained child deaths. Mechanisms underlying SUDC, like SUID, remain largely speculative. Limited and inconsistent evidence implicates abnormalities in brainstem autonomic and serotonergic nuclei, critical for arousal, cardiorespiratory control, and reflex responses to life-threatening hypoxia or hypercarbia in sleep (6). Abnormalities in medullary serotonergic neurons and receptors, as well as cardiorespiratory brainstem nuclei occur in some SUID cases, but have never been studied in SUDC. Retrospective, small SUDC studies with non-standardized methodologies most often demonstrate minor hippocampal abnormalities, as well as focal cortical dysplasia and dysgenesis of the brainstem and cerebellum. The significance of these findings to SUDC pathogenesis remains unclear with some investigators and forensic pathologists labeling these findings as normal variants, or potential causes of SUDC. The development of preventive strategies will require a greater understanding of underlying mechanisms.
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Affiliation(s)
- Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Laura G Crandall
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, United States.,SUDC Foundation, Herndon, VA, United States
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, United States
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15
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Crandall LG, Lee JH, Friedman D, Lear K, Maloney K, Pinckard JK, Lin P, Andrew T, Roman K, Landi K, Jarrell H, Williamson AK, Downs JCU, Pinneri K, William C, Maleszewski JJ, Reichard RR, Devinsky O. Evaluation of Concordance Between Original Death Certifications and an Expert Panel Process in the Determination of Sudden Unexplained Death in Childhood. JAMA Netw Open 2020; 3:e2023262. [PMID: 33125496 PMCID: PMC7599447 DOI: 10.1001/jamanetworkopen.2020.23262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The true incidence of sudden unexplained death in childhood (SUDC), already the fifth leading category of death among toddlers by current US Centers for Disease Control and Prevention estimates, is potentially veiled by the varied certification processes by medicolegal investigative offices across the United States. OBJECTIVE To evaluate the frequency of SUDC incidence, understand its epidemiology, and assess the consistency of death certification among medical examiner and coroner offices in the US death investigation system. DESIGN, SETTING, AND PARTICIPANTS In this case series, 2 of 13 forensic pathologists (FPs) conducted masked reviews of 100 cases enrolled in the SUDC Registry and Research Collaborative (SUDCRRC). Children who died aged 11 months to 18 years from 36 US states, Canada, and the United Kingdom had been posthumously enrolled in the SUDCRRC by family members from 2014 to 2017. Comprehensive data from medicolegal investigative offices, clinical offices, and family members were reviewed. Data analysis was conducted from December 2014 to June 2020. MAIN OUTCOMES AND MEASURES Certified cause of death (COD) characterized as explained (accidental or natural) or unexplained, as determined by SUDCRRC masked review process. RESULTS In this study of 100 cases of SUDC (mean [SD] age, 32.1 [31.8] months; 58 [58.0%] boys; 82 [82.0%] White children; 92 [92.0%] from the United States), the original pathologist certified 43 cases (43.0%) as explained COD and 57 (57.0%) as unexplained COD. The SUDCRRC review process led to the following certifications: 16 (16.0%) were explained, 7 (7.0%) were undetermined because of insufficient data, and 77 (77.0%) were unexplained. Experts disagreed with the original COD in 40 cases (40.0%). These data suggest that SUDC incidence is higher than the current Centers for Disease Control and Prevention estimate (ie, 392 deaths in 2018). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first comprehensive masked forensic pathology review process of sudden unexpected pediatric deaths, and it suggests that SUDC may often go unrecognized in US death investigations. Some unexpected pediatric deaths may be erroneously attributed to a natural or accidental COD, negatively affecting surveillance, research, public health funding, and medical care of surviving family members. To further address the challenges of accurate and consistent death certification in SUDC, future studies are warranted.
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Affiliation(s)
| | - Joyce H. Lee
- NYU Grossman School of Medicine, New York, New York
| | | | - Kelly Lear
- Arapahoe County Coroner’s Office, Centennial, Colorado
| | - Katherine Maloney
- Erie County Medical Examiner's Office, Buffalo, New York
- University at Buffalo School of Medicine, Buffalo, New York
| | | | | | - Thomas Andrew
- White Mountain Forensic Consulting Services, Concord, New Hampshire
| | | | | | | | | | | | - Kathy Pinneri
- Montgomery County Forensic Services Department, Conroe, Texas
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16
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Kon FC, Vázquez RZ, Lang A, Cohen MC. Hippocampal abnormalities and seizures: a 16-year single center review of sudden unexpected death in childhood, sudden unexpected death in epilepsy and SIDS. Forensic Sci Med Pathol 2020; 16:423-434. [PMID: 32712908 DOI: 10.1007/s12024-020-00268-7] [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] [Accepted: 05/19/2020] [Indexed: 12/27/2022]
Abstract
Sudden Unexpected Death in Childhood (SUDC) is the unexplained death of children aged between 1 and 18 years old. Hippocampal abnormalities have previously been described in Sudden Unexpected Death in Epilepsy (SUDEP) and it is possible that SUDC shares similar pathogenic mechanisms with SUDEP. Our aim was to determine the prevalence of hippocampal abnormalities, history of seizures and demographic features in our caseload of SUDC, SUDEP and SIDS cases. A review of post-mortem reports from 2003 to 2018 was carried out to identify cases of SUDC, SUDEP and SIDS. Histological evidence of hippocampal abnormalities, patient demographics (age, gender), sleeping position, and past medical history (history of seizures and illness 72 hours prior to death) were recorded. Statistical analysis was performed to compare the three groups. 48 SUDC, 18 SUDEP and 358 SIDS cases were identified. Hippocampal abnormalities associated with temporal lobe epilepsy were found in 44.4% of SUDC cases. 5/15 SUDC cases with a history of seizures demonstrated hippocampal abnormalities. SUDC cases were also more likely to be found prone compared to SIDS cases. In comparison with SIDS, both SUDC and SUDEP cases were more likely to demonstrate hippocampal abnormalities (SUDC: (OR = 9.4, 95% CI: 3.1-29.1, p < 0.001; SUDEP: OR = 35.4, 95% CI: 8.3-151.5, p < 0.001). We found a potential link between hippocampal abnormalities and epileptic seizures in SUDC. A concerted effort should be directed towards consistent sampling and standardized description of the hippocampus and clinical correlation with a history of seizures/epilepsy in postmortem reports.
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Affiliation(s)
- Fu Chuen Kon
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK.,Medical School, University of Sheffield, Sheffield, UK
| | | | - Andrew Lang
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK
| | - Marta C Cohen
- Histopathology Department, Sheffield Children's Hospital NHS FT, Sheffield, UK. .,Department of Oncology & Metabolism, University of Sheffield, Sheffield, UK.
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17
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Postural change for supine position does not disturb toddlers' nap. Sci Rep 2020; 10:11944. [PMID: 32686727 PMCID: PMC7371876 DOI: 10.1038/s41598-020-68832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 06/22/2020] [Indexed: 11/08/2022] Open
Abstract
This study examined whether forced postural change from prone to supine during toddlers’ nap, a preventative measure taken in Japan for sudden unexplained death in childhood (SUDC), disturbs toddlers’ sleep. When the "Back to Sleep" campaign (BSC) was introduced to Japan in 1996, its recommendations were also applied to infants aged 1 year old and over with the expectation that the BSC recommendations may also contribute to a decrease in the occurrence rate of SUDC. Since then, Japanese nurseries have routinely conducted sleeping position checks and positional adjustments of toddlers every 5–10 min during naps. A total of 52 toddlers (age 18.4 ± 3.3 months, means ± SD) were continuously monitored for 8 h during daytime at nursery schools for wake-sleep status and body position (prone, supine and lateral) with actigraphs and 3-orthogonal-axis accelerometers. Out of the 52 toddlers, 24 toddlers adopted prone positions during naps, which were adjusted by nursery staff back to supine. When nursery staff manually changed the toddlers position from prone to supine, the toddlers either did not wake or woke only briefly (3.1 ± 4.9 min) and returned to sleep soon after the positional change. Our study indicates that manual change of toddlers’ sleeping position from prone to supine, a potential SUDC prevention method, does not disturb toddlers’ sleep during their naps.
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18
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McGuone D, Leitner D, William C, Faustin A, Leelatian N, Reichard R, Shepherd TM, Snuderl M, Crandall L, Wisniewski T, Devinsky O. Neuropathologic Changes in Sudden Unexplained Death in Childhood. J Neuropathol Exp Neurol 2020; 79:336-346. [PMID: 31995186 PMCID: PMC7036658 DOI: 10.1093/jnen/nlz136] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/14/2019] [Accepted: 12/10/2019] [Indexed: 12/21/2022] Open
Abstract
Sudden unexplained death in childhood (SUDC) affects children >1-year-old whose cause of death remains unexplained following comprehensive case investigation and is often associated with hippocampal abnormalities. We prospectively performed systematic neuropathologic investigation in 20 SUDC cases, including (i) autopsy data and comprehensive ancillary testing, including molecular studies, (ii) ex vivo 3T MRI and extensive histologic brain samples, and (iii) blinded neuropathology review by 2 board-certified neuropathologists. There were 12 girls and 8 boys; median age at death was 33.3 months. Twelve had a history of febrile seizures, 85% died during apparent sleep and 80% in prone position. Molecular testing possibly explained 3 deaths and identified genetic mutations in TNNI3, RYR2, and multiple chromosomal aberrations. Hippocampal abnormalities most often affected the dentate gyrus (altered thickness, irregular configuration, and focal lack of granule cells), and had highest concordance between reviewers. Findings were identified with similar frequencies in cases with and without molecular findings. Number of seizures did not correlate with hippocampal findings. Hippocampal alterations were the most common finding on histological review but were also found in possibly explained deaths. The significance and specificity of hippocampal findings is unclear as they may result from seizures, contribute to seizure pathogenesis, or be an unrelated phenomenon.
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Affiliation(s)
- Declan McGuone
- From the Department of Pathology, Yale School of Medicine, New haven, Connecticut
| | - Dominique Leitner
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
| | - Christopher William
- Department of Neurology
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York
| | | | - Nalin Leelatian
- From the Department of Pathology, Yale School of Medicine, New haven, Connecticut
| | - Ross Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Matija Snuderl
- Department of Pathology, NYU Langone Health and School of Medicine, New York, New York
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
- Sudden Unexplained Death in Childhood Foundation, Cedar Grove, New Jersey
| | - Thomas Wisniewski
- Department of Neurology
- Center for Cognitive Neurology, and Psychiatry, NYU Langone Health and School of Medicine, New York, New York
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, New York
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19
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Epilepsy and seizure-related deaths: Mortality statistics do not tell the complete story. Epilepsy Behav 2019; 98:266-272. [PMID: 31408827 DOI: 10.1016/j.yebeh.2019.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The objective of the study was to identify where epilepsy or seizures may be the underlying cause of death but not identified by the death certification process in the Australian coronial system and to better characterize such deaths. METHODS Australian National Coronial Information System (NCIS) closed cases for the Australian Capital Territory (ACT) (population average 348,000) over 13 years were searched using cause of death, and a text search of police and autopsy reports, to identify all deaths where epilepsy or seizures were mentioned. Deaths where the underlying cause of death was not seizures or epilepsy were excluded (including suicide). The remaining cases (75) were categorized by the circumstances of death. Suspected sudden unexpected death in epilepsy (SUDEP) cases were further classified using the unified definition of SUDEP of Nashef and colleagues (2012). RESULTS Of the final 75 cases, only 44 were found by the cause of death search. Key word document searches found another 31. Cases were classified as Definite SUDEP (37), Definite SUDEP Plus (10), Probable SUDEP (1), Possible SUDEP (3), Near SUDEP (4), Near SUDEP Plus (1), Asphyxia (3), Treatment-related (1), Head injury (2), Drowning (2), motor vehicle accident (MVA) (1), deaths related to a single convulsive seizure (6), and status epilepticus (SE) (4). Cases were 80% male. CONCLUSIONS Epilepsy and seizure-related deaths are underreported in the Australian Coronial system. Enhanced documentation of the causal chain of events leading to deaths would increase recognition. Using the unified SUDEP definition would expand SUDEP identification.
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20
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Somani A, Zborovschi AB, Liu Y, Patodia S, Michalak Z, Sisodiya SM, Thom M. Hippocampal morphometry in sudden and unexpected death in epilepsy. Neurology 2019; 93:e804-e814. [PMID: 31345959 DOI: 10.1212/wnl.0000000000007969] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine hippocampal morphometric measures, including granule cell dispersion and features of malrotation, as potential biomarkers for sudden unexpected death in epilepsy (SUDEP) from an archival postmortem series. METHODS In a retrospective study of 187 archival postmortems from 3 groups, SUDEP (68; 14 with hippocampal sclerosis [HS]), non-SUDEP epilepsy controls (EP-C = 66; 25 with HS), and nonepilepsy controls (NEC = 53), Nissl/hematoxylin & eosin-stained sections from left and right hippocampus from 5 coronal levels were digitized. Image analysis was carried out for granule cell layer (GCL) thickness and measurements of hippocampal dimensions (HD) for shape (width [HD1], height [HD2]) and medial hippocampal positioning in relation to the parahippocampal gyrus (PHG) length (HD3). A qualitative evaluation of hippocampal malrotational (HMAL) features, dentate gyrus invaginations (DGI), and subicular/CA1 folds (SCF) was also made. RESULTS GCL thickness was increased in HS more than those without (p < 0.001). In non-HS cases, increased GCL thickness was noted in EP-C compared to NEC (p < 0.05) but not between SUDEP and NEC. There was no difference in the frequency of DGI, SCF, measurements of hippocampal shape (HD1, HD2, or ratio), or medial positioning among SUDEP, EP-C, and NEC groups, when factoring in HS, coronal level, and age at death. Comparison between left and right sides within cases showed greater PHG lengths (HD3) on the right side in the SUDEP group only (p = 0.018). CONCLUSIONS No hippocampal morphometric features were identified in support of either excessive granule cell dispersion or features of HMAL as definitive biomarkers for SUDEP. Asymmetries in PHG measurements in SUDEP warrant further investigation as they may indicate abnormal central autonomic networks.
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Affiliation(s)
- Alyma Somani
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Anita-Beatrix Zborovschi
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Yan Liu
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Smriti Patodia
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Zuzanna Michalak
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Sanjay M Sisodiya
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK
| | - Maria Thom
- From the Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, Queen Square, London, UK.
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21
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Verducci C, Hussain F, Donner E, Moseley BD, Buchhalter J, Hesdorffer D, Friedman D, Devinsky O. SUDEP in the North American SUDEP Registry: The full spectrum of epilepsies. Neurology 2019; 93:e227-e236. [PMID: 31217259 PMCID: PMC6656646 DOI: 10.1212/wnl.0000000000007778] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/15/2019] [Indexed: 11/23/2022] Open
Abstract
Objective To obtain medical records, family interviews, and death-related reports of sudden unexpected death in epilepsy (SUDEP) cases to better understand SUDEP. Methods All cases referred to the North American SUDEP Registry (NASR) between October 2011 and June 2018 were reviewed; cause of death was determined by consensus review. Available medical records, death scene investigation reports, autopsy reports, and next-of-kin interviews were reviewed for all cases of SUDEP. Seizure type, EEG, MRI, and SUDEP classification were adjudicated by 2 epileptologists. Results There were 237 definite and probable cases of SUDEP among 530 NASR participants. SUDEP decedents had a median age of 26 (range 1–70) years at death, and 38% were female. In 143 with sufficient information, 40% had generalized and 60% had focal epilepsy. SUDEP affected the full spectrum of epilepsies, from benign epilepsy with centrotemporal spikes (n = 3, 1%) to intractable epileptic encephalopathies (n = 27, 11%). Most (93%) SUDEPs were unwitnessed; 70% occurred during apparent sleep; and 69% of patients were prone. Only 37% of cases of SUDEP took their last dose of antiseizure medications (ASMs). Reported lifetime generalized tonic-clonic seizures (GTCS) were <10 in 33% and 0 in 4%. Conclusions NASR participants commonly have clinical features that have been previously been associated with SUDEP risk such as young adult age, ASM nonadherence, and frequent GTCS. However, a sizeable minority of SUDEP occurred in patients thought to be treatment responsive or to have benign epilepsies. These results emphasize the importance of SUDEP education across the spectrum of epilepsy severities. We aim to make NASR data and biospecimens available for researchers to advance SUDEP understanding and prevention.
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Affiliation(s)
- Chloe Verducci
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Fizza Hussain
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Elizabeth Donner
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Brian D Moseley
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Jeffrey Buchhalter
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Dale Hesdorffer
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Daniel Friedman
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY
| | - Orrin Devinsky
- From the Comprehensive Epilepsy Center (C.V., F.H., D.F., O.D.), New York University School of Medicine, NY; Division of Neurology (E.D.), The Hospital for Sick Children, Toronto, Ontario, Canada; Epilepsy Center (B.D.M.), Gardner Neuroscience Institute, University of Cincinnati Health, OH; Department of Pediatrics (J.B.), University of Calgary, Alberta, Canada; and Gertrude H. Sergievsky Center (D.H.), Division of Epidemiology, Columbia University Medical Center, New York, NY.
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22
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Stampe NK, Glinge C, Jabbari R, Bjune T, Risgaard B, Tfelt-Hansen J, Winkel BG. Febrile seizures prior to sudden cardiac death: a Danish nationwide study. Europace 2019; 20:f192-f197. [PMID: 29186479 DOI: 10.1093/europace/eux335] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/11/2017] [Indexed: 11/12/2022] Open
Abstract
Aims Febrile seizure (FS) is a common disorder affecting 2-5% of children up to 5 years of age. The aim of this study was to determine whether FS in early childhood are over-represented in young adults dying from sudden cardiac death (SCD). Methods and results We included all deaths (n = 4595) nationwide and through review of all death certificates, we identified 245 SCD in Danes aged 1-30 years in 2000-09. Through the usage of nationwide registries, we identified all persons admitted with first FS among SCD cases (14/245; 5.7%) and in the corresponding living Danish population (71 027/2 369 785; 3.0%) and also in victims of transport accidents (26/917; 2.8%). The frequency of FS among SCD cases was significantly increased by an odds ratio of 1.96 [95% confidence interval (CI) 1.14-3.36; P = 0.021] compared with the living Danish population and with an odds ratio of 2.08 (95% CI 1.07-4.04; P = 0.046) compared with transport accident victims. SCD cases did not differ statistically in birth year (P = 0.272), age at SCD (P = 0.667) or prior medical conditions, except for epilepsy (P < 0.001), when comparing SCD with and without prior FS. The most common cause of death in autopsied SCD cases with FS was sudden arrhythmic death syndrome (5/8; 62.5%). Conclusion In conclusion, this study demonstrates a significantly two-fold increase in the frequency of FS prior to death in young SCD cases compared with the two control groups, suggesting that FS could potentially contribute in a risk stratification model for SCD and warrant further studies.
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Affiliation(s)
- Niels Kjær Stampe
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Charlotte Glinge
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Thea Bjune
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Bjarke Risgaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
| | - Bo Gregers Winkel
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark
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23
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Crandall LG, Lee JH, Stainman R, Friedman D, Devinsky O. Potential Role of Febrile Seizures and Other Risk Factors Associated With Sudden Deaths in Children. JAMA Netw Open 2019; 2:e192739. [PMID: 31026025 PMCID: PMC6487567 DOI: 10.1001/jamanetworkopen.2019.2739] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Sudden unexplained death in childhood (SUDC) is the fifth leading category of death among toddlers but remains underrecognized and inadequately studied. OBJECTIVE To assess the potential role of febrile seizures (FS) and other risk factors associated with SUDC and describe the epidemiology, mechanisms, and prevention of SUDC. DESIGN, SETTING, AND PARTICIPANTS This case series study reviewed 622 consecutive sudden child death cases aged 1 to 17 years from 2001 to 2017 from 18 countries. Data were collected from family members of children who died suddenly; these families voluntarily registered with the SUDC Foundation. Data analysis was conducted from November 2017 to February 2019. MAIN OUTCOME MEASURES Certified manner of death characterized as accident, natural, or undetermined. RESULTS A total of 391 families with decedents aged 1 to 6 years completed a comprehensive interview on medical and social histories, and circumstances of death with forensic evaluations revealing a cause of death (sudden explained death in childhood [SEDC]) or no cause of death (SUDC). Of these children, 231 (59.1%) were male, the mean (SD) age at death was 24.9 (12.8) months, and 104 (26.6%) had a history of FS. Compared with the general population FS prevalence (2%-5%), FS prevalence among SUDC (28.8%; 95% CI, 23.3%-34.2%) and SEDC (22.1%; 95% CI, 14.8%-29.3%) were elevated. The odds of death during sleep was 4.6-fold higher in SUDC than in SEDC cases (odds ratio, 4.61; 95% CI, 1.92-11.09; adjusted P = .008). The siblings of SUDC cases were followed up for 3144 life-years, and none died prematurely from SUDC. CONCLUSIONS AND RELEVANCE This analysis of the largest SUDC cohort confirmed an increased FS rate and found significantly increased rates of FS among SEDC. This study suggests that seizures may contribute to some SUDC and SEDC deaths. The risk of sudden death in a sibling was low. To develop and assess preventive strategies, population-based studies are needed to define the epidemiology and spectrum of risk factors and identify biomarkers of patients with FS at high risk of sudden death.
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Affiliation(s)
- Laura Gould Crandall
- Sudden Unexplained Death In Childhood Foundation, Roseland, New Jersey
- New York University School of Medicine, Comprehensive Epilepsy Center, New York
| | - Joyce H. Lee
- New York University School of Medicine, Comprehensive Epilepsy Center, New York
| | - Rebecca Stainman
- New York University School of Medicine, Comprehensive Epilepsy Center, New York
| | - Daniel Friedman
- New York University School of Medicine, Comprehensive Epilepsy Center, New York
| | - Orrin Devinsky
- New York University School of Medicine, Comprehensive Epilepsy Center, New York
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24
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Hoch MJ, Bruno MT, Faustin A, Cruz N, Crandall L, Wisniewski T, Devinsky O, Shepherd TM. 3T MRI Whole-Brain Microscopy Discrimination of Subcortical Anatomy, Part 1: Brain Stem. AJNR Am J Neuroradiol 2019; 40:401-407. [PMID: 30705073 DOI: 10.3174/ajnr.a5956] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/12/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE The brain stem is compactly organized with life-sustaining sensorimotor and autonomic structures that can be affected by numerous pathologies but can be difficult to resolve on conventional MR imaging. MATERIALS AND METHODS We applied an optimized TSE T2 sequence to washed postmortem brain samples to reveal exquisite and reproducible brain stem anatomic MR imaging contrast comparable with histologic atlases. This resource-efficient approach can be performed across multiple whole-brain samples with relatively short acquisition times (2 hours per imaging plane) using clinical 3T MR imaging systems. RESULTS We identified most brain stem structures at 7 canonical axial levels. Multiplanar or oblique planes illustrate the 3D course and spatial relationships of major brain stem white matter pathways. Measurements of the relative position, course, and cross-sectional area of these pathways across multiple samples allow estimation of pathway location in other samples or clinical subjects. Possible structure-function asymmetries in these pathways will require further study-that is, the cross-sectional area of the left corticospinal tract in the midpons appeared 20% larger (n = 13 brains, P < .10). CONCLUSIONS Compared with traditional atlases, multiplanar MR imaging contrast has advantages for learning and retaining brain stem anatomy for clinicians and trainees. Direct TSE MR imaging sequence discrimination of brain stem anatomy can help validate other MR imaging contrasts, such as diffusion tractography, or serve as a structural template for extracting quantitative MR imaging data in future postmortem investigations.
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Affiliation(s)
- M J Hoch
- From the Department of Radiology and Imaging Sciences (M.J.H.), Emory University, Atlanta, Georgia
| | - M T Bruno
- Departments of Radiology (M.T.B., N.C., T.M.S.)
| | | | - N Cruz
- Departments of Radiology (M.T.B., N.C., T.M.S.)
| | - L Crandall
- Neurology (L.C., T.W., O.D.)
- SUDC Registry and Research Collaborative (L.C., O.D.), New York, New York
| | - T Wisniewski
- Neurology (L.C., T.W., O.D.)
- Psychiatry (T.W.), New York University, New York, New York
| | - O Devinsky
- Neurology (L.C., T.W., O.D.)
- SUDC Registry and Research Collaborative (L.C., O.D.), New York, New York
| | - T M Shepherd
- Departments of Radiology (M.T.B., N.C., T.M.S.)
- Center for Advanced Imaging Innovation and Research (T.M.S.), New York, New York
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25
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Thom M, Boldrini M, Bundock E, Sheppard MN, Devinsky O. Review: The past, present and future challenges in epilepsy-related and sudden deaths and biobanking. Neuropathol Appl Neurobiol 2019; 44:32-55. [PMID: 29178443 PMCID: PMC5820128 DOI: 10.1111/nan.12453] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/14/2017] [Indexed: 12/14/2022]
Abstract
Awareness and research on epilepsy-related deaths (ERD), in particular Sudden Unexpected Death in Epilepsy (SUDEP), have exponentially increased over the last two decades. Most publications have focused on guidelines that inform clinicians dealing with these deaths, educating patients, potential risk factors and mechanisms. There is a relative paucity of information available for pathologists who conduct these autopsies regarding appropriate post mortem practice and investigations. As we move from recognizing SUDEP as the most common form of ERD toward in-depth investigations into its causes and prevention, health professionals involved with these autopsies and post mortem procedure must remain fully informed. Systematizing a more comprehensive and consistent practice of examining these cases will facilitate (i) more precise determination of cause of death, (ii) identification of SUDEP for improved epidemiological surveillance (the first step for an intervention study), and (iii) biobanking and cell-based research. This article reviews how pathologists and healthcare professionals have approached ERD, current practices, logistical problems and areas to improve and harmonize. The main neuropathology, cardiac and genetic findings in SUDEP are outlined, providing a framework for best practices, integration of clinical, pathological and molecular genetic investigations in SUDEP, and ultimately prevention.
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Affiliation(s)
- M Thom
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK
| | - M Boldrini
- Department of Psychiatry, Columbia University Medical Centre, Divisions of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - E Bundock
- Office of the Chief Medical Examiner, Burlington, VT, USA
| | - M N Sheppard
- Department of Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - O Devinsky
- Department of Neurology, NYU Epilepsy Center, New York, NY, USA
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26
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Dreier JW, Pedersen CB, Cotsapas C, Christensen J. Childhood seizures and risk of psychiatric disorders in adolescence and early adulthood: a Danish nationwide cohort study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 3:99-108. [PMID: 30528754 DOI: 10.1016/s2352-4642(18)30351-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Paediatric seizures have been linked to psychiatric disorders in childhood, but there is a paucity of large-scale population-based studies of psychiatric comorbidity in later life. We aimed to examine the relation between childhood seizures and the risk of psychiatric disorders in adolescence and early adulthood. METHODS We did a register-based cohort study of all individuals born in Denmark in 1978-2002. Using diagnostic information from the Danish National Patient Register, all cohort members were categorised according to occurrence of febrile seizures and epilepsy, before entering the follow-up period on their 10th birthday. Individuals were followed up until onset of mental illness, death, emigration, or the end of the study period on Dec 31, 2012. Cox regression analyses were used to estimate the risk of five predefined groups of psychiatric disorders (substance abuse disorders, schizophrenia, mood disorder, anxiety, and personality disorder), separately and combined. Models were adjusted for relevant confounders. FINDINGS Between Jan 1, 1978, and Dec 31, 2002, 1 291 679 individuals were born in Denmark and followed up in our population cohort (approximately 15 million person-years). 43 148 individuals had a history of febrile seizures, 10 355 had epilepsy, and 1696 had both these disorders. 83 735 (6%) cohort members were identified with at least one of the psychiatric disorders of interest. The risk of any psychiatric disorder was raised in individuals with a history of febrile seizures (hazard ratio [HR] 1·12, 95% CI 1·08-1·17), epilepsy (1·34, 1·25-1·44), or both disorders (1·50, 1·28-1·75). Excess risk of psychiatric illness associated with childhood seizures was present across a range of different disorders, most notably schizophrenia but also anxiety and mood disorders. Associations did not differ between males and females (p=0·30) but increased with a growing number of admissions for febrile seizures (p<0·0001) and with later onset of childhood epilepsy (p<0·0001). INTERPRETATION Children with epilepsy and febrile seizures-with and without concomitant epilepsy-are at increased risk of developing a broad range of psychiatric disorders in later life. Clarification of the underlying mechanisms attributable to these associations is needed to identify potential options for prevention. FUNDING Novo Nordisk Foundation, Danish Epilepsy Association, Central Denmark Region, Lundbeck Foundation, and Stanley Medical Research Institute.
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Affiliation(s)
- Julie W Dreier
- National Center for Register-Based Research, Aarhus University, Aarhus, Denmark; Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark.
| | - Carsten B Pedersen
- National Center for Register-Based Research, Aarhus University, Aarhus, Denmark; Centre for Integrated Register-based Research, CIRRAU, Aarhus University, Aarhus, Denmark; Lundbeck Foundation Initiative for Integrative Psychiatric Research, iPSYCH, Aarhus University, Aarhus, Denmark
| | - Chris Cotsapas
- Broad Institute of Harvard and MIT, Cambridge, MA, USA; Department of Neurology and Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Jakob Christensen
- National Center for Register-Based Research, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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27
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Saxena A, Jones L, Shankar R, McLean B, Newman CGJ, Hamandi K. Sudden unexpected death in epilepsy in children: a focused review of incidence and risk factors. J Neurol Neurosurg Psychiatry 2018; 89:1064-1070. [PMID: 29632029 DOI: 10.1136/jnnp-2017-317702] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/21/2018] [Accepted: 03/12/2018] [Indexed: 11/04/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) in children, although rare, needs critical attention given the tragic nature and devastating consequences for families and caregivers. True incidence is unknown and risk factors are not completely understood, more so in children compared with adults. A focused narrative review of available studies on paediatric SUDEP was undertaken to comprehend its risk factors and to develop strategies to recognise and where possible modify SUDEP risk and ultimately reduce incidence. We reviewed 16 population-based studies from various settings. We found overlapping risk factors from different studies. The prime risk factor is uncontrolled seizures. This review supports the view that children entering adolescence with optimal seizure control could be a key aspect in reducing adult mortality related to SUDEP. Ideally, clinicians would want to be able to predict prospective, individualised SUDEP risk, which is challenging due to a myriad of risk factors and an inherent non-homogeneous paediatric epilepsy population. Nevertheless, an adequate evidence base exists as evidenced by this review to support information giving and communication to support young people with epilepsy and their families in being active partners in recognising and reducing their SUDEP risk. More work particularly in the form of prospective studies and registries are needed to further clarify true incidence which may have been previously underestimated and to update risk factors.
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Affiliation(s)
- Anurag Saxena
- The Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | | | | | | | - Craig G J Newman
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Khalid Hamandi
- Wales Epilepsy Unit, Department of Neurology, University Hospital of Wales, Cardiff, UK
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28
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Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context 2018; 7:212536. [PMID: 30038660 PMCID: PMC6052913 DOI: 10.7573/dic.212536] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 12/14/2022] Open
Abstract
Background Febrile seizures are the most common neurologic disorder in childhood. Physicians should be familiar with the proper evaluation and management of this common condition. Objective To provide an update on the current understanding, evaluation, and management of febrile seizures. Methods A PubMed search was completed in Clinical Queries using the key terms ‘febrile convulsions’ and ‘febrile seizures’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Results Febrile seizures, with a peak incidence between 12 and 18 months of age, likely result from a vulnerability of the developing central nervous system to the effects of fever, in combination with an underlying genetic predisposition and environmental factors. The majority of febrile seizures occur within 24 hours of the onset of the fever. Febrile seizures can be simple or complex. Clinical judgment based on variable presentations must direct the diagnostic studies which are usually not necessary in the majority of cases. A lumbar puncture should be considered in children younger than 12 months of age or with suspected meningitis. Children with complex febrile seizures are at risk of subsequent epilepsy. Approximately 30–40% of children with a febrile seizure will have a recurrence during early childhood. The prognosis is favorable as the condition is usually benign and self-limiting. Intervention to stop the seizure often is unnecessary. Conclusion Continuous preventative antiepileptic therapy for the prevention of recurrent febrile seizures is not recommended. The use of intermittent anticonvulsant therapy is not routinely indicated. Antipyretics have no role in the prevention of febrile seizures.
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Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Pediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Theresa Nh Leung
- Department of Pediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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29
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Brownstein CA, Goldstein RD, Thompson CH, Haynes RL, Giles E, Sheidley B, Bainbridge M, Haas EA, Mena OJ, Lucas J, Schaber B, Holm IA, George AL, Kinney HC, Poduri AH. SCN1A variants associated with sudden infant death syndrome. Epilepsia 2018; 59:e56-e62. [PMID: 29601086 DOI: 10.1111/epi.14055] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 12/27/2022]
Abstract
We identified SCN1A variants in 2 infants who died of sudden infant death syndrome (SIDS) with hippocampal abnormalities from an exome sequencing study of 10 cases of SIDS but no history of seizures. One harbored SCN1A G682V, and the other had 2 SCN1A variants in cis: L1296M and E1308D, a variant previously associated with epilepsy. Functional evaluation in a heterologous expression system demonstrated partial loss of function for both G682V and the compound variant L1296M/E1308D. Our cases represent a novel association between SCN1A and SIDS, extending the SCN1A spectrum from epilepsy to SIDS. Our findings provide insights into SIDS and support genetic evaluation focused on epilepsy genes in SIDS.
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Affiliation(s)
- Catherine A Brownstein
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Genetics and Genomics, Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard D Goldstein
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Christopher H Thompson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robin L Haynes
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Emma Giles
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Beth Sheidley
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | | | - Elisabeth A Haas
- Department of Pathology, Rady Children's Hospital-San Diego, San Diego, CA, USA
| | - Othon J Mena
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Jonathan Lucas
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Bethann Schaber
- Office of the Medical Examiner, County of San Diego Medical Examiner's Office, San Diego, CA, USA
| | - Ingrid A Holm
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Division of Genetics and Genomics, Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Alfred L George
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hannah C Kinney
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Annapurna H Poduri
- Robert's Program on Sudden Death in Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, F. M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
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30
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Devinsky O, Friedman D, Cheng JY, Moffatt E, Kim A, Tseng ZH. Underestimation of sudden deaths among patients with seizures and epilepsy. Neurology 2017; 89:886-892. [PMID: 28768851 DOI: 10.1212/wnl.0000000000004292] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/28/2017] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To determine the definite and potential frequency of seizures and epilepsy as a cause of death (COD) and how often this goes unrecognized. METHODS Prospective determination of seizures or epilepsy and final COD for individuals aged 18-90 years with out-of-hospital sudden cardiac deaths (SCDs) from the population-based San Francisco POST SCD Study. We compared prospective seizure or epilepsy diagnosis and final COD as adjudicated by a multidisciplinary committee (pathologists, electrophysiologists, and a vascular neurologist) vs retrospective adjudication by 2 epileptologists with expertise in seizure-related mortality. RESULTS Of 541 SCDs identified during the 37-month study period (mean age 62.8 years, 69% men), 525 (97%) were autopsied; 39/525 (7.4%) had seizures or epilepsy (mean age: 58 years, range: 27-92; 67% men), comprising 17% of 231 nonarrhythmic sudden deaths. The multidisciplinary team identified 15 cases of epilepsy, 6 sudden unexpected deaths in epilepsy (SUDEPs), and no deaths related to acute symptomatic seizures. The epileptologists identified 25 cases of epilepsy and 8 definite SUDEPs, 10 possible SUDEPs, and 5 potential cases of acute symptomatic seizures as a COD. CONCLUSIONS Among the 25 patients identified with epilepsy by the epileptologists, they found definite or possible SUDEP in 72% (18/25) vs 24% (6/25) by the multidisciplinary group (6/15 cases they identified with epilepsy). The epileptologists identified acute symptomatic seizures as a potential COD in 5/14 patients with alcohol-related seizures. Epilepsy is underdiagnosed among decedents. Among patients with seizures and epilepsy who die suddenly, seizures and SUDEP often go unrecognized as a potential or definite COD.
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Affiliation(s)
- Orrin Devinsky
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine.
| | - Daniel Friedman
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine
| | - Jocelyn Y Cheng
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine
| | - Ellen Moffatt
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine
| | - Anthony Kim
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine
| | - Zian H Tseng
- From the Department of Neurology (O.D., D.F., J.Y.C.), Epilepsy Center, NYU School of Medicine; and Department of Pathology (E.M.), Department of Neurology (A.K.), and Electrophysiology and Arrhythmia Service (Z.H.T.), Department of Medicine, UCSF School of Medicine
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31
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Crandall L, Devinsky O. Sudden unexplained death in children. THE LANCET CHILD & ADOLESCENT HEALTH 2017; 1:8-9. [PMID: 30169231 DOI: 10.1016/s2352-4642(17)30003-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Laura Crandall
- Department of Neurology, NYU School of Medicine, Comprehensive Epilepsy Center, New York, NY 110016, USA.
| | - Orrin Devinsky
- Department of Neurology, NYU School of Medicine, Comprehensive Epilepsy Center, New York, NY 110016, USA
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A survey of medical examiner death certification of vignettes on death in epilepsy: Gaps in identifying SUDEP. Epilepsy Res 2017; 133:71-75. [DOI: 10.1016/j.eplepsyres.2017.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/31/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
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Donner EJ, Camfield P, Brooks L, Buchhalter J, Camfield C, Loddenkemper T, Wirrell E. Understanding Death in Children With Epilepsy. Pediatr Neurol 2017; 70:7-15. [PMID: 28242084 DOI: 10.1016/j.pediatrneurol.2017.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/11/2017] [Indexed: 11/19/2022]
Abstract
Death in children with epilepsy is profoundly disturbing, with lasting effects on the family, community, and health care providers. The overall risk of death for children with epilepsy is about ten times that of the general population. However, the risk of premature death for children without associated neurological comorbidities is similar to that of the general population, and most deaths are related to the cause of the epilepsy or associated neurological disability, not seizures. The most common cause of seizure-related death in children with epilepsy is sudden unexpected death in epilepsy (SUDEP). SUDEP is relatively uncommon in childhood, but the risk increases if epilepsy persists into adulthood. Although the direct cause of SUDEP remains unknown, most often death follows a generalized convulsive seizure and the risk of SUDEP is strongly related to drug-resistant epilepsy and frequent generalized tonic-clonic seizures. The most effective SUDEP prevention strategy is to reduce the frequency of seizures, although a number of seizure detection devices are under development and in the future may prove to be useful for seizure detection for those at particularly high risk. There are distinct benefits for health care professionals to discuss mortality with the family soon after the diagnosis of epilepsy. An individual approach is appropriate. When a child with epilepsy dies, particularly if the death was unexpected, family grief may be profound. Physicians and other health care professionals have a critical role in supporting families that lose a child to epilepsy. This review will provide health care providers with information needed to discuss the risk of death in children with epilepsy and support families following a loss.
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Affiliation(s)
- Elizabeth J Donner
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Peter Camfield
- Department of Pediatrics, Dalhousie University and the IWK Health Centre, Halifax, NS, Canada
| | - Linda Brooks
- The SUDEP Institute, Epilepsy Foundation, Landover, Maryland
| | - Jeffrey Buchhalter
- Department of Paediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carol Camfield
- Department of Pediatrics, Dalhousie University and the IWK Health Centre, Halifax, NS, Canada
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Dlouhy BJ, Ciliberto MA, Cifra CL, Kirby PA, Shrock DL, Nashelsky M, Richerson GB. Unexpected Death of a Child with Complex Febrile Seizures-Pathophysiology Similar to Sudden Unexpected Death in Epilepsy? Front Neurol 2017; 8:21. [PMID: 28203222 PMCID: PMC5286923 DOI: 10.3389/fneur.2017.00021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 01/13/2017] [Indexed: 12/26/2022] Open
Abstract
Febrile seizures are usually considered relatively benign. Although some cases of sudden unexplained death in childhood have a history of febrile seizures, no documented case of febrile seizure-induced death has been reported. Here, we describe a child with complex febrile seizures who died suddenly and unexpectedly after a suspected seizure while in bed at night during the beginning phases of sleep. She was resuscitated and pronounced brain dead 2 days later at our regional medical center. Autopsy revealed multiorgan effects of hypoperfusion and did not reveal an underlying (precipitating) disease, injury, or toxicological cause of death. Although a seizure was not witnessed, it was suspected as the underlying cause of death based on the medical examiner and forensic pathologist (author Marcus Nashelsky) investigation, the post-resuscitation clinical findings, and multiple aspects of the clinical history. The child had a history of complex febrile seizures that had previously caused apnea and oxygen desaturation. She had two febrile seizures earlier on the same day of the fatal event. Interestingly, her mother also experienced a febrile seizure as a child, which led to respiratory arrest requiring cardiorespiratory resuscitation. This case suggests that in a child with complex febrile seizures, a seizure can induce death in a manner that is consistent with the majority of cases of sudden unexpected death in epilepsy (SUDEP). Further work is needed to better understand how and why certain individuals, with a history of epilepsy or not, die suddenly and unexpectedly from seizures. This will only occur through better understanding of the pathophysiologic mechanisms underlying epileptic and febrile seizures and death from seizures including SUDEP.
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Affiliation(s)
- Brian J Dlouhy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Pappajohn Biomedical Institute, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael A Ciliberto
- Department of Pediatrics, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
| | - Christina L Cifra
- Department of Pediatrics, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
| | - Patricia A Kirby
- Department of Pathology, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
| | - Devin L Shrock
- Department of Pathology, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
| | - Marcus Nashelsky
- Department of Pathology, University of Iowa Hospitals and Clinics , Iowa City, IA , USA
| | - George B Richerson
- Pappajohn Biomedical Institute, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Michalak Z, Obari D, Ellis M, Thom M, Sisodiya SM. Neuropathology of SUDEP: Role of inflammation, blood-brain barrier impairment, and hypoxia. Neurology 2017; 88:551-561. [PMID: 28087824 PMCID: PMC5304466 DOI: 10.1212/wnl.0000000000003584] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 11/09/2016] [Indexed: 12/12/2022] Open
Abstract
Objective: To seek a neuropathologic signature of sudden unexpected death in epilepsy (SUDEP) in a postmortem cohort by use of immunohistochemistry for specific markers of inflammation, gliosis, acute neuronal injury due to hypoxia, and blood-brain barrier (BBB) disruption, enabling the generation of hypotheses about potential mechanisms of death in SUDEP. Methods: Using immunohistochemistry, we investigated the expression of 6 markers (CD163, human leukocyte antigen–antigen D related, glial fibrillary acid protein, hypoxia-inducible factor-1α [HIF-1α], immunoglobulin G, and albumin) in the hippocampus, amygdala, and medulla in 58 postmortem cases: 28 SUDEP (definite and probable), 12 epilepsy controls, and 18 nonepileptic sudden death controls. A semiquantitative measure of immunoreactivity was scored for all markers used, and quantitative image analysis was carried out for selected markers. Results: Immunoreactivity was observed for all markers used within all studied brain regions and groups. Immunoreactivity for inflammatory reaction, BBB leakage, and HIF-1α in SUDEP cases was not different from that seen in control groups. Conclusions: This study represents a starting point to explore by immunohistochemistry the mechanisms underlying SUDEP in human brain tissue. Our approach highlights the potential and importance of considering immunohistochemical analysis to help identify biomarkers of SUDEP. Our results suggest that with the markers used, there is no clear immunohistochemical signature of SUDEP in human brain.
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Affiliation(s)
- Zuzanna Michalak
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Dima Obari
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Matthew Ellis
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Maria Thom
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK
| | - Sanjay M Sisodiya
- From the Department of Clinical and Experimental Epilepsy (Z.M., D.O., M.T., S.M.S.), University College London, and Department of Neuropathology (Z.M., D.O., M.E., M.T.), Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK; and Epilepsy Society (S.M.S.), Chalfont St. Peter, Bucks, UK.
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Christy A, Nyhan W, Wilson J. Severe Respiratory Acidosis in Status Epilepticus as a Possible Etiology of Sudden Death in Lesch-Nyhan Disease: A Case Report and Review of the Literature. JIMD Rep 2016; 35:23-28. [PMID: 27858372 DOI: 10.1007/8904_2016_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/18/2016] [Accepted: 10/21/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Lesch-Nyhan disease (LND) is an X-linked disorder of purine metabolism, associated with self-mutilation, dystonia, and chorea. Seizures are uncommon in LND. Patients with LND are at risk for sudden and unexpected death. The etiology of this is unknown, but appears to occur from a respiratory process. We propose that respiratory failure secondary to subclinical seizure may lead to sudden death in these patients. CASE We report a case of an 11-year-old boy with LND who had two episodes of nocturnal gasping. The second event was immediately followed by a 10 min generalized seizure. Upon arrival at the hospital, an arterial blood gas test revealed a severe respiratory acidosis. Following aggressive treatment of his seizures, this patient did well, and was discharged home on oxcarbazepine with rectal diazepam. No further seizures have been noted in 1 year of follow-up. CONCLUSIONS In this case report and review, we hypothesize that sudden death from respiratory failure in Lesch-Nyhan disease may in some cases be due to seizure-induced respiratory failure, akin to sudden unexpected death in epilepsy (SUDEP). We suggest screening for paroxysmal respiratory events; consideration of electroencephalography for patients with LND presenting in respiratory distress or failure; and consideration of more aggressive treatment of seizures in these patients. Brief Summary:We present an 11-year-old boy with Lesch-Nyhan disease (LND) who developed respiratory failure and severe respiratory acidosis from his first known seizure, which evolved to subclinical status epilepticus. We propose that patients with LND have a predisposition to respiratory failure and sudden death, which in some cases may be provoked by seizure (sudden unexpected death in epilepsy, or SUDEP).
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Affiliation(s)
- Alison Christy
- Department of Pediatric Neurology, Oregon Health and Science University, Mail Code CDRC-P, 707 SW Gaines Street, Portland, OR, 97239, USA.
| | - William Nyhan
- Department of Pediatrics, University of California, 9500 Gilman Drive #0830, La Jolla, San Diego, CA, 92093, USA
| | - Jenny Wilson
- Department of Pediatric Neurology, Oregon Health and Science University, Mail Code CDRC-P, 707 SW Gaines Street, Portland, OR, 97239, USA
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Abstract
Authors: Kevin D Graber, MD, Jeffrey Buchhalter, MD, PhD, Elson So, MD, Rainer Surges, MD, Detlev Boison, PhD, Franck Kalume, PhD, Cyndi Wright, Brian Gehlbach, MD, Jeff Noebels, MD, PhD, Vicky Whittemore, PhD, Elizabeth J. Donner, MD, MSc, Tom Stanton, MPP, Henry Smithson, MD, Jane Hanna, Masud Seyal, MD, PhD, Philippe Ryvlin, MD, PhD The third biannual Partners Against Mortality in Epilepsy (PAME) conference was held in Alexandria, VA from June 23-26, 2016. This was an intimate meeting of clinical and basic scientists, clinicians, people affected by Sudden Unexpected Death in Epilepsy Patients (SUDEP) in a loved one, people living with epilepsy and patient advocate organizations. Plenary sessions have been summarized by moderators, including: 1) Mortality in people with epilepsy: epidemiology and surveillance. 2) Mortality in children. 3) What do we know about the factors that predispose certain people to die from a seizure? 4) What are the events that occur during and after a seizure that cause a death in SUDEP? 5) What are the options for prevention now and in the future? 6) Advocacy perspectives: how can we speed up awareness and prevention? 7) Updates and discussion on select programs in mortality research. Breakout sessions allowed for a more focused audience. Those summarized here are: Frequent non-SUDEP causes of mortality in people with epilepsy; Mechanisms of SUDEP; Lessons learned in grief and how to better support families; Future directions for research to impact prevention; and How do we improve SUDEP risk disclosure? While significant progress has been made with review of human mortality in epilepsy and study of animal models, this meeting emphasized the need for: better understandings of the epidemiology of SUDEP, advances in the understandings of mechanisms, continued search for biomarkers and preventative measures, patient education, increased awareness, continued advocacy for patient and family support and research funding.
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Devinsky O, Hesdorffer DC, Thurman DJ, Lhatoo S, Richerson G. Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention. Lancet Neurol 2016; 15:1075-88. [DOI: 10.1016/s1474-4422(16)30158-2] [Citation(s) in RCA: 369] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/24/2022]
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Rutecki PA, Sutula TP. Hippocampal abnormalities and sudden childhood death. Forensic Sci Med Pathol 2016; 12:200-1. [DOI: 10.1007/s12024-016-9767-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
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Calton MA, Howard JR, Harper RM, Goldowitz D, Mittleman G. The Cerebellum and SIDS: Disordered Breathing in a Mouse Model of Developmental Cerebellar Purkinje Cell Loss during Recovery from Hypercarbia. Front Neurol 2016; 7:78. [PMID: 27242661 PMCID: PMC4865515 DOI: 10.3389/fneur.2016.00078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/02/2016] [Indexed: 12/05/2022] Open
Abstract
The cerebellum assists coordination of somatomotor, respiratory, and autonomic actions. Purkinje cell alterations or loss appear in sudden infant death and sudden death in epilepsy victims, possibly contributing to the fatal event. We evaluated breathing patterns in 12 wild-type (WT) and Lurcher mutant mice with 100% developmental cerebellar Purkinje cell loss under baseline (room air), and recovery from hypercapnia, a concern in sudden death events. Six mutant and six WT mice were exposed to 4-min blocks of increasing CO2 (2, 4, 6, and 8%), separated by 4-min recovery intervals in room air. Breath-by-breath patterns, including depth of breathing and end-expiratory pause (EEP) durations during recovery, were recorded. No baseline genotypic differences emerged. However, during recovery, EEP durations significantly lengthened in mutants, compared to WT mice, following the relatively low levels of CO2 exposure. Additionally, mutant mice exhibited signs of post-sigh disordered breathing during recovery following each exposure. Developmental cerebellar Purkinje cell loss significantly affects compensatory breathing patterns following mild CO2 exposure, possibly by inhibiting recovery from elevated CO2. These data implicate cerebellar Purkinje cells in the ability to recover from hypercarbia, suggesting that neuropathologic changes or loss of these cells contribute to inadequate ventilatory recovery to increased environmental CO2. Multiple disorders, including sudden infant death syndrome (SIDS) and sudden unexpected death in epilepsy (SUDEP), appear to involve both cardiorespiratory failure and loss or injury to cerebellar Purkinje cells; the findings support the concept that such neuropathology may precede and exert a prominent role in these fatal events.
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Affiliation(s)
- Michele A Calton
- Department of Psychology, The University of Memphis , Memphis, TN , USA
| | - Jeremy R Howard
- Department of Psychology, The University of Memphis , Memphis, TN , USA
| | - Ronald M Harper
- Neurobiology, David Geffen School of Medicine, University of California, Los Angeles , Los Angeles, CA , USA
| | - Dan Goldowitz
- Centre for Molecular Medicine and Therapeutics, University of British Columbia , Vancouver, BC , Canada
| | - Guy Mittleman
- Department of Psychological Science, Ball State University , Muncie, IN , USA
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Holt RL, Arehart E, Hunanyan A, Fainberg NA, Mikati MA. Pediatric Sudden Unexpected Death in Epilepsy: What Have we Learned from Animal and Human Studies, and Can we Prevent it? Semin Pediatr Neurol 2016; 23:127-33. [PMID: 27544469 DOI: 10.1016/j.spen.2016.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Several factors, such as epilepsy syndrome, poor compliance, and increased seizure frequency increase the risks of sudden unexpected death in epilepsy (SUDEP). Animal models have revealed that the mechanisms of SUDEP involve initially a primary event, often a seizure of sufficient type and severity, that occurs in a brain, which is vulnerable to SUDEP due to either genetic or antecedent factors. This primary event initiates a cascade of secondary events starting, as some models indicate, with cortical spreading depolarization that propagates to the brainstem where it results in autonomic dysfunction. Intrinsic abnormalities in brainstem serotonin, adenosine, sodium-postassium ATPase, and respiratory-control systems are also important. The tertiary event, which results from the above dysfunction, consists of either lethal central apnea, pulmonary edema, or arrhythmia. Currently, it is necessary to (1) continue researching SUDEP mechanisms, (2) work on reducing SUDEP risk factors, and (3) address the major need to counsel families about SUDEP.
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Affiliation(s)
- Rebecca L Holt
- Division of Pediatric Neurology, Lucile Packard Children's Hospital at Stanford University, Palo Alto, CA
| | - Eric Arehart
- Division of Pediatric Neurology, Children's Health Center, Duke University Medical Center, Durham, NC
| | - Arsen Hunanyan
- Division of Pediatric Neurology, Children's Health Center, Duke University Medical Center, Durham, NC
| | - Nina A Fainberg
- Division of Pediatric Neurology, Children's Health Center, Duke University Medical Center, Durham, NC
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Children's Health Center, Duke University Medical Center, Durham, NC.
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Abstract
BACKGROUND Epilepsy is a common neurological disorder among children and adolescents that is associated with increased mortality for numerous reasons. Sudden unexpected death in epilepsy is a critically important entity for physicians who treat patients with epilepsy. Many pediatric neurologists are hesitant to discuss this condition with patients and families because of the lower risk in the pediatric age group. METHODS We searched for studies published between January 2000 and June 2015 by means of a PubMed search and a cumulative review of reference lists of all relevant publications, using the keywords "sudden unexpected death in epilepsy patients," "pediatric SUDEP," "sudden unexpected death in epilepsy patients and children," "sudden unexpected death in children" and "sudden infant death syndrome." RESULTS SUDEP is a rare condition in children. Its mechanism is poorly understood and may have a distinct pathogenesis from adult sudden unexpected death in epilepsy. Limited comfort, experience, and knowledge to provide appropriate education about sudden unexpected death in epilepsy leads to fewer physicians discussing this subject leading to less informed and less prepared patients and families. CONCLUSION We provide a detailed review of the literature on pediatric SUDEP, including the definition, classification, and proposed mechanisms of sudden unexpected death in epilepsy in children, as well as discuss the incidence in the pediatric population and risk factors in children, concluding with possible prevention strategies.
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Sivakumar SS, Namath AG, Tuxhorn IE, Lewis SJ, Galán RF. Decreased heart rate and enhanced sinus arrhythmia during interictal sleep demonstrate autonomic imbalance in generalized epilepsy. J Neurophysiol 2016; 115:1988-99. [PMID: 26888110 DOI: 10.1152/jn.01120.2015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/15/2016] [Indexed: 02/07/2023] Open
Abstract
We hypothesized that epilepsy affects the activity of the autonomic nervous system even in the absence of seizures, which should manifest as differences in heart rate variability (HRV) and cardiac cycle. To test this hypothesis, we investigated ECG traces of 91 children and adolescents with generalized epilepsy and 25 neurologically normal controls during 30 min of stage 2 sleep with interictal or normal EEG. Mean heart rate (HR) and high-frequency HRV corresponding to respiratory sinus arrhythmia (RSA) were quantified and compared. Blood pressure (BP) measurements from physical exams of all subjects were also collected and analyzed. RSA was on average significantly stronger in patients with epilepsy, whereas their mean HR was significantly lower after adjusting for age, body mass index, and sex, consistent with increased parasympathetic tone in these patients. In contrast, diastolic (and systolic) BP at rest was not significantly different, indicating that the sympathetic tone is similar. Remarkably, five additional subjects, initially diagnosed as neurologically normal but with enhanced RSA and lower HR, eventually developed epilepsy, suggesting that increased parasympathetic tone precedes the onset of epilepsy in children. ECG waveforms in epilepsy also displayed significantly longer TP intervals (ventricular diastole) relative to the RR interval. The relative TP interval correlated positively with RSA and negatively with HR, suggesting that these parameters are linked through a common mechanism, which we discuss. Altogether, our results provide evidence for imbalanced autonomic function in generalized epilepsy, which may be a key contributing factor to sudden unexpected death in epilepsy.
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Affiliation(s)
- Siddharth S Sivakumar
- Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Amalia G Namath
- Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Ingrid E Tuxhorn
- Division of Pediatric Epilepsy, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Stephen J Lewis
- Division of Pulmonology, Allergy and Immunology, Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio; and
| | - Roberto F Galán
- Department of Electrical Engineering and Computer Science, School of Engineering, Case Western Reserve University, Cleveland, Ohio
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Hefti MM, Cryan JB, Haas EA, Chadwick AE, Crandall LA, Trachtenberg FL, Armstrong DD, Grafe M, Krous HF, Kinney HC. Hippocampal malformation associated with sudden death in early childhood: a neuropathologic study. Forensic Sci Med Pathol 2016; 12:14-25. [DOI: 10.1007/s12024-015-9731-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 11/28/2022]
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Halvorsen M, Petrovski S, Shellhaas R, Tang Y, Crandall L, Goldstein D, Devinsky O. Mosaic mutations in early-onset genetic diseases. Genet Med 2015; 18:746-9. [PMID: 26716362 DOI: 10.1038/gim.2015.155] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/16/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE An emerging approach in medical genetics is to identify de novo mutations in patients with severe early-onset genetic disease that are absent in population controls and in the patient's parents. This approach, however, frequently misses post-zygotic "mosaic" mutations that are present in only a portion of the healthy parents' cells and are transmitted to offspring. METHODS We constructed a mosaic transmission screen for variants that have an ~50% alternative allele ratio in the proband but are significantly less than 50% in the transmitting parent. We applied it to two family-based genetic disease cohorts consisting of 9 cases of sudden unexplained death in childhood (SUDC) and 338 previously published cases of epileptic encephalopathy. RESULTS The screen identified six parental-mosaic transmissions across the two cohorts. The resultant rate of ~0.02 identified transmissions per trio is far lower than that of de novo mutations. Among these transmissions were two likely disease-causing mutations: an SCN1A mutation transmitted to an SUDC proband and her sibling with Dravet syndrome, as well as an SLC6A1 mutation in a proband with epileptic encephalopathy. CONCLUSION These results highlight explicit screening for mosaic mutations as an important complement to the established approach of screening for de novo mutations.Genet Med 18 7, 746-749.
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Affiliation(s)
- Matt Halvorsen
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Slavé Petrovski
- Institute for Genomic Medicine, Columbia University, New York, New York, USA.,Department of Medicine, The University of Melbourne, Austin Health and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Renée Shellhaas
- Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Yingying Tang
- Molecular Genetics Laboratory, New York City Office of the Chief Medical Examiner, New York, New York, USA.,Department of Pathology, NYU Langone Medical Center, New York, New York, USA
| | - Laura Crandall
- SUDC Foundation, Herndon, Virginia, USA.,Comprehensive Epilepsy Center, Department of Neurology, NYU Langone Medical Center, New York, New York, USA
| | - David Goldstein
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, Department of Neurology, NYU Langone Medical Center, New York, New York, USA
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Cui W, Kobau R, Zack MM, Helmers S, Yeargin-Allsopp M. Seizures in Children and Adolescents Aged 6-17 Years - United States, 2010-2014. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2015; 64:1209-14. [PMID: 26540283 DOI: 10.15585/mmwr.mm6443a2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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