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Karakis I. Epilepsy Is Associated With Increased Long-Term Risk of Cardiac Arrhythmias: Did Your Heart Skip a Beat? Epilepsy Curr 2024; 24:99-101. [PMID: 39280047 PMCID: PMC11394412 DOI: 10.1177/15357597231225088] [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] [Indexed: 09/18/2024] Open
Abstract
[Box: see text]
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Affiliation(s)
- Ioannis Karakis
- Department of Neurology, Emory University School of Medicine & University of Crete School of Medicine
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Senapati SG, Bhanushali AK, Lahori S, Naagendran MS, Sriram S, Ganguly A, Pusa M, Damani DN, Kulkarni K, Arunachalam SP. Mapping of Neuro-Cardiac Electrophysiology: Interlinking Epilepsy and Arrhythmia. J Cardiovasc Dev Dis 2023; 10:433. [PMID: 37887880 PMCID: PMC10607576 DOI: 10.3390/jcdd10100433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/10/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
The interplay between neurology and cardiology has gained significant attention in recent years, particularly regarding the shared pathophysiological mechanisms and clinical comorbidities observed in epilepsy and arrhythmias. Neuro-cardiac electrophysiology mapping involves the comprehensive assessment of both neural and cardiac electrical activity, aiming to unravel the intricate connections and potential cross-talk between the brain and the heart. The emergence of artificial intelligence (AI) has revolutionized the field by enabling the analysis of large-scale data sets, complex signal processing, and predictive modeling. AI algorithms have been applied to neuroimaging, electroencephalography (EEG), electrocardiography (ECG), and other diagnostic modalities to identify subtle patterns, classify disease subtypes, predict outcomes, and guide personalized treatment strategies. In this review, we highlight the potential clinical implications of neuro-cardiac mapping and AI in the management of epilepsy and arrhythmias. We address the challenges and limitations associated with these approaches, including data quality, interpretability, and ethical considerations. Further research and collaboration between neurologists, cardiologists, and AI experts are needed to fully unlock the potential of this interdisciplinary field.
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Affiliation(s)
- Sidhartha G. Senapati
- Department of Internal Medicine, Texas Tech University Health and Sciences Center, El Paso, TX 79905, USA; (S.G.S.); (D.N.D.)
| | - Aditi K. Bhanushali
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
| | - Simmy Lahori
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
| | | | - Shreya Sriram
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Arghyadeep Ganguly
- Department of Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI 49007, USA;
| | - Mounika Pusa
- Mamata Medical College, Khammam 507002, Telangana, India;
| | - Devanshi N. Damani
- Department of Internal Medicine, Texas Tech University Health and Sciences Center, El Paso, TX 79905, USA; (S.G.S.); (D.N.D.)
- Department of Cardiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kanchan Kulkarni
- IHU-LIRYC, Heart Rhythm Disease Institute, Fondation Bordeaux Université, Pessac, 33600 Bordeaux, France;
- INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, U1045, 33000 Bordeaux, France
| | - Shivaram P. Arunachalam
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (A.K.B.); (S.L.)
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Kim JY, Shin J, Kim L, Kim SH. Electroencephalography characteristics related to risk of sudden unexpected death in epilepsy in patients with Dravet syndrome. Front Neurol 2023; 14:1222721. [PMID: 37745659 PMCID: PMC10512954 DOI: 10.3389/fneur.2023.1222721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Objective To investigate the quantitative electroencephalography (EEG) features associated with a high risk of sudden unexpected death in epilepsy (SUDEP) in patients with Dravet syndrome (DS). Methods Patients with DS and healthy controls (HCs) who underwent EEG were included in the study. EEG signals were recorded using a 21 channel digital EEG system, and pre-processed data were analyzed to identify quantitative EEG features associated with a high SUDEP risk. To assess the risk of SUDEP, SUDEP-7 scores were used. Results A total of 64 patients with DS [38 males and 26 females, aged: 128.51 ± 75.50 months (range: 23-380 months)], and 13 HCs [7 males and 6 females, aged: 95.46 ± 86.48 months (range: 13-263 months)] were included. For the absolute band power, the theta power was significantly higher in the high-SUDEP group than in the low-SUDEP group in the central brain region. For the relative band power, the theta power was also significantly higher in the high-SUDEP group than in the low-SUDEP group in the central and occipital brain regions. The alpha power was significantly lower in the high-SUDEP group than in the low-SUDEP group in the central and parietal brain regions. Conclusion Patients with high SUDEP-7 scores have different EEG features from those with low SUDEP-7 scores, suggesting that EEG may be used as a biomarker of SUDEP in DS. Significance Early intervention in patients with DS at a high risk of SUDEP can reduce mortality and morbidity. Patients with high theta band powers warrant high-level supervision.
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Affiliation(s)
- Jeong-Youn Kim
- Electronics and Telecommunication Research Institute (ETRI), Daejeon, Republic of Korea
| | - Jeongyoon Shin
- School of Electrical and Electronic Engineering, College of Engineering, Yonsei University, Seoul, Republic of Korea
- Yonsei Biomedical Research Institute, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Laehyun Kim
- Center for Bionics, Korea Institute of Science and Technology, Seoul, Republic of Korea
- Department of HY-KIST Bio-Convergence, Hanyang University, Seoul, Republic of Korea
| | - Se Hee Kim
- Pediatric Neurology, Department of Pediatrics, Epilepsy Research Institute, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Giussani G, Falcicchio G, La Neve A, Costagliola G, Striano P, Scarabello A, Mostacci B, Beghi E. Sudden unexpected death in epilepsy: A critical view of the literature. Epilepsia Open 2023; 8:728-757. [PMID: 36896633 PMCID: PMC10472423 DOI: 10.1002/epi4.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus in which postmortem examination does not reveal other causes of death. Lower diagnostic levels are assigned when cases met most or all of these criteria, but data suggested more than one possible cause of death. The incidence of SUDEP ranged from 0.09 to 2.4 per 1000 person-years. Differences can be attributed to the age of the study populations (with peaks in the 20-40-year age group) and the severity of the disease. Young age, disease severity (in particular, a history of generalized TCS), having symptomatic epilepsy, and the response to antiseizure medications (ASMs) are possible independent predictors of SUDEP. The pathophysiological mechanisms are not fully known due to the limited data available and because SUDEP is not always witnessed and has been electrophysiologically monitored only in a few cases with simultaneous assessment of respiratory, cardiac, and brain activity. The pathophysiological basis of SUDEP may vary according to different circumstances that make that particular seizure, in that specific moment and in that patient, a fatal event. The main hypothesized mechanisms, which could contribute to a cascade of events, are cardiac dysfunction (included potential effects of ASMs, genetically determined channelopathies, acquired heart diseases), respiratory dysfunction (included postictal arousal deficit for the respiratory mechanism, acquired respiratory diseases), neuromodulator dysfunction, postictal EEG depression and genetic factors.
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Affiliation(s)
- Giorgia Giussani
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | | | - Pasquale Striano
- IRCCS Istituto “Giannina Gaslini”GenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Anna Scarabello
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
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Gravitis AC, Tufa U, Zukotynski K, Streiner DL, Friedman D, Laze J, Chinvarun Y, Devinsky O, Wennberg R, Carlen PL, Bardakjian BL. Ictal ECG-based assessment of sudden unexpected death in epilepsy. Front Neurol 2023; 14:1147576. [PMID: 36994379 PMCID: PMC10040863 DOI: 10.3389/fneur.2023.1147576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
IntroductionPrevious case-control studies of sudden unexpected death in epilepsy (SUDEP) patients failed to identify ECG features (peri-ictal heart rate, heart rate variability, corrected QT interval, postictal heart rate recovery, and cardiac rhythm) predictive of SUDEP risk. This implied a need to derive novel metrics to assess SUDEP risk from ECG.MethodsWe applied Single Spectrum Analysis and Independent Component Analysis (SSA-ICA) to remove artifact from ECG recordings. Then cross-frequency phase-phase coupling (PPC) was applied to a 20-s mid-seizure window and a contour of −3 dB coupling strength was determined. The contour centroid polar coordinates, amplitude (alpha) and angle (theta), were calculated. Association of alpha and theta with SUDEP was assessed and a logistic classifier for alpha was constructed.ResultsAlpha was higher in SUDEP patients, compared to non-SUDEP patients (p < 0.001). Theta showed no significant difference between patient populations. The receiver operating characteristic (ROC) of a logistic classifier for alpha resulted in an area under the ROC curve (AUC) of 94% and correctly classified two test SUDEP patients.DiscussionThis study develops a novel metric alpha, which highlights non-linear interactions between two rhythms in the ECG, and is predictive of SUDEP risk.
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Affiliation(s)
- Adam C. Gravitis
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Uilki Tufa
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Katherine Zukotynski
- Department of Radiology, McMaster University, Hamilton, ON, Canada
- Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada
| | - David L. Streiner
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Daniel Friedman
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Juliana Laze
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Yotin Chinvarun
- Department of Medicine, Phramongkutklao Royal Army Hospital, Bangkok, Thailand
| | - Orrin Devinsky
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Richard Wennberg
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Peter L. Carlen
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Berj L. Bardakjian
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada
- *Correspondence: Berj L. Bardakjian
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6
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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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Talavera B, Hupp NJ, Melius S, Lhatoo SD, Lacuey N. Protocols for multimodal polygraphy for cardiorespiratory monitoring in the epilepsy monitoring unit. Part I: Clinical acquisition. Epilepsy Res 2022; 185:106990. [PMID: 35930940 DOI: 10.1016/j.eplepsyres.2022.106990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Multimodal polygraphy including cardiorespiratory monitoring in the Epilepsy Monitoring is becoming increasingly important. In addition to simultaneous recording of video and EEG, the combination of these techniques not only improves seizure detection, it enhances patient safety and provides information on autonomic clinical symptoms, which may be contributory to localization of seizure foci. However, there are currently no consensus guidelines, nor adequate information on devices available for multimodal polygraphy for cardiorespiratory monitoring in the Epilepsy Monitoring Unit. Our purpose here is to provide protocols and information on devices for such monitoring. Suggested parameters include respiratory inductance plethysmography (thoraco-abdominal belts for respiratory rate), pulse oximetry and four-lead electrocardiography. Detailed knowledge of devices, their operability and acquisition optimization enables accurate interpretation of signal and differentiation of abnormalities from artifacts. Multimodal polygraphy brings new opportunities for identification of peri-ictal cardiorespiratory abnormalities, and may identify high SUDEP risk individuals.
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Affiliation(s)
- Blanca Talavera
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA.
| | - Norma J Hupp
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Stephen Melius
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Samden D Lhatoo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
| | - Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, TX, USA
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8
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Chen ZS, Hsieh A, Sun G, Bergey GK, Berkovic SF, Perucca P, D'Souza W, Elder CJ, Farooque P, Johnson EL, Barnard S, Nightscales R, Kwan P, Moseley B, O'Brien TJ, Sivathamboo S, Laze J, Friedman D, Devinsky O. Interictal EEG and ECG for SUDEP Risk Assessment: A Retrospective Multicenter Cohort Study. Front Neurol 2022; 13:858333. [PMID: 35370908 PMCID: PMC8973318 DOI: 10.3389/fneur.2022.858333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related mortality. Although lots of effort has been made in identifying clinical risk factors for SUDEP in the literature, there are few validated methods to predict individual SUDEP risk. Prolonged postictal EEG suppression (PGES) is a potential SUDEP biomarker, but its occurrence is infrequent and requires epilepsy monitoring unit admission. We use machine learning methods to examine SUDEP risk using interictal EEG and ECG recordings from SUDEP cases and matched living epilepsy controls. Methods This multicenter, retrospective, cohort study examined interictal EEG and ECG recordings from 30 SUDEP cases and 58 age-matched living epilepsy patient controls. We trained machine learning models with interictal EEG and ECG features to predict the retrospective SUDEP risk for each patient. We assessed cross-validated classification accuracy and the area under the receiver operating characteristic (AUC) curve. Results The logistic regression (LR) classifier produced the overall best performance, outperforming the support vector machine (SVM), random forest (RF), and convolutional neural network (CNN). Among the 30 patients with SUDEP [14 females; mean age (SD), 31 (8.47) years] and 58 living epilepsy controls [26 females (43%); mean age (SD) 31 (8.5) years], the LR model achieved the median AUC of 0.77 [interquartile range (IQR), 0.73–0.80] in five-fold cross-validation using interictal alpha and low gamma power ratio of the EEG and heart rate variability (HRV) features extracted from the ECG. The LR model achieved the mean AUC of 0.79 in leave-one-center-out prediction. Conclusions Our results support that machine learning-driven models may quantify SUDEP risk for epilepsy patients, future refinements in our model may help predict individualized SUDEP risk and help clinicians correlate predictive scores with the clinical data. Low-cost and noninvasive interictal biomarkers of SUDEP risk may help clinicians to identify high-risk patients and initiate preventive strategies.
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Affiliation(s)
- Zhe Sage Chen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, United States
- Neuroscience Institute, New York University Grossman School of Medicine, New York, NY, United States
- *Correspondence: Zhe Sage Chen
| | - Aaron Hsieh
- Tandon School of Engineering, New York University, New York, NY, United States
| | - Guanghao Sun
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, United States
| | - Gregory K. Bergey
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Samuel F. Berkovic
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Wendyl D'Souza
- Department of Medicine, St. Vincent's Hospital, The University of Melbourne, Fitzroy, VIC, Australia
| | - Christopher J. Elder
- Division of Epilepsy and Sleep, Columbia University, New York, NY, United States
| | - Pue Farooque
- Yale University School of Medicine, New Haven, CT, United States
| | - Emily L. Johnson
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sarah Barnard
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, United States
| | - Russell Nightscales
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Brian Moseley
- Clinical Development Neurocrine Biosciences Inc., San Diego, CA, United States
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Shobi Sivathamboo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Juliana Laze
- Comprehensive Epilepsy Center, New York University Langone Health, New York, NY, United States
| | - Daniel Friedman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, United States
- Comprehensive Epilepsy Center, New York University Langone Health, New York, NY, United States
| | - Orrin Devinsky
- Neuroscience Institute, New York University Grossman School of Medicine, New York, NY, United States
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, United States
- Comprehensive Epilepsy Center, New York University Langone Health, New York, NY, United States
- Orrin Devinsky
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9
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Harte S, Singh Y, Malone S, Heussler H, Wallace G. Cannabidiol and refractory epilepsy: parental and caregiver perspectives of participation in a compassionate access scheme. BMC Health Serv Res 2022; 22:173. [PMID: 35144615 PMCID: PMC8832815 DOI: 10.1186/s12913-022-07592-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background The Compassionate Access Scheme (CAS) being delivered through the Queensland Children’s Hospital is designed to allow access to an investigational purified Cannabidiol oral solution to paediatric patients with severe refractory epilepsy. The objectives of this study were to conduct semi-structured interviews to: 1. Understand families’ expectations and attitudes about the use of an investigational cannabinoid product for their child’s seizures; 2. Understand families’ perceptions of Cannabidiol’s efficacy for their child’s seizures; and other aspects of their child’s behaviour, quality of life and/or cognition. Methods Children aged 2-18 years had been enrolled in, or were enrolled in a compassionate access scheme for Cannabidiol at the time of the study. Semi-structured interviews (n = 19) with parents or caregivers (n = 23) of children diagnosed with refractory epilepsy were voice-recorded, transcribed and analysed to generate common themes. Results Key themes emerged relating to seizure activity, family and school engagement, drug safety and legal access, efficacy, clinical support, social acceptance of the medication and program delivery. The use of Cannabidiol was perceived to have benefits in relation to reducing the severity and frequency of seizure activity for almost a third of patients experiencing refractory epilepsy. Participants described other benefits including improved social engagement, wakefulness and a reduction of side effects related to a reduction of conventional medication dosage. Conclusion This study provided unique perspectives of families’ experiences managing untreatable epilepsy, their experiences with conventional and experimental pharmacological treatments and health services. Whilst families’ perceptions showed the use of Cannabidiol did not provide a therapeutic reduction in the seizure activity for all patients diagnosed with refractory epilepsy, it’s use as an additional pharmacological agent was perceived to provide other benefits by some patient families.
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Affiliation(s)
- S Harte
- The University of Queensland, School of Medicine, Brisbane, Australia.
| | - Y Singh
- Queensland Children's Hospital, South Brisbane, Australia
| | - S Malone
- Queensland Children's Hospital, South Brisbane, Australia
| | - H Heussler
- Queensland Children's Hospital, South Brisbane, Australia.
| | - G Wallace
- Queensland Children's Hospital, South Brisbane, Australia
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10
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Heart rate variability in patients with refractory epilepsy: The influence of generalized convulsive seizures. Epilepsy Res 2021; 178:106796. [PMID: 34763267 DOI: 10.1016/j.eplepsyres.2021.106796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients with epilepsy, mainly drug-resistant, have reduced heart rate variability (HRV), linked to an increased risk of sudden death in various other diseases. In this context, it could play a role in SUDEP. Generalized convulsive seizures (GCS) are one of the most consensual risk factors for SUDEP. Our objective was to assess the influence of GCS in HRV parameters in patients with drug-resistant epilepsy. METHODS We prospectively evaluated 121 patients with refractory epilepsy admitted to our Epilepsy Monitoring Unit. All patients underwent a 48-hour Holter recording. Only patients with GCS were included (n = 23), and we selected the first as the index seizure. We evaluated HRV (AVNN, SDNN, RMSSD, pNN50, LF, HF, and LF/HF) in 5-min epochs (diurnal and nocturnal baselines; preictal - 5 min before the seizure; ictal; postictal - 5 min after the seizure; and late postictal - >5 h after the seizure). These data were also compared with normative values from a healthy population (controlling for age and gender). RESULTS We included 23 patients, with a median age of 36 (min-max, 16-55) years and 65% were female. Thirty percent had cardiovascular risk factors, but no previously known cardiac disease. HRV parameters AVNN, RMSSD, pNN50, and HF were significantly lower in the diurnal than in the nocturnal baseline, whereas the opposite occurred with LF/HF and HR. Diurnal baseline parameters were inferior to the normative population values (which includes only diurnal values). We found significant differences in HRV parameters between the analyzed periods, especially during the postictal period. All parameters but LF/HF suffered a reduction in that period. LF/HF increased in that period but did not reach statistical significance. Visually, there was a tendency for a global reduction in our patients' HRV parameters, namely AVNN, RMSSD, and pNN50, in each period, comparing with those from a normative healthy population. No significant differences were found in HRV between diurnal and nocturnal seizures, between temporal lobe and extra-temporal-lobe seizures, between seizures with and without postictal generalized EEG suppression, or between seizures of patients with and without cardiovascular risk factors. SIGNIFICANCE/CONCLUSION Our work reinforces the evidence of autonomic cardiac dysfunction in patients with refractory epilepsy, at baseline and mainly in the postictal phase of a GCS. Those changes may have a role in some SUDEP cases. By identifying patients with worse autonomic cardiac function, HRV could fill the gap of a lacking SUDEP risk biomarker.
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Abstract
The brain and heart are closely interconnected. Physiologically, the brain influences the way the heart beats. An example for this physiological influence is the control of the heart rate via efferences of the autonomic nervous system. Clinical examples for this direction of interactions include cardiac complications after stroke as well as takotsubo cardiomyopathy; however, the heart and brain are reciprocally connected so that heart activity also influences the brain beyond its function as the generator of bloodflow supplying the brain. Examples for this are the perception of stimuli depending on the time of presentation during the heart cycle. Clinical examples of the direction of this interaction constitute stroke as a thromboembolic complication of atrial fibrillation as well as the correlation of atrial fibrillation and dementia. This review article gives an overview of the bidirectional interactions between the heart and brain, partly including the cardiovascular system, discusses their implications for the clinical routine and gives an outlook on current fields of research.
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12
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Nei M, Pickard A. The role of convulsive seizures in SUDEP. Auton Neurosci 2021; 235:102856. [PMID: 34343824 DOI: 10.1016/j.autneu.2021.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/01/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022]
Abstract
Convulsive seizures are the most consistently reported risk factor for SUDEP. However, the precise mechanisms by which convulsive seizures trigger fatal cardiopulmonary changes are still unclear. Additionally, it is not clear why some seizures cause death when most do not. This article reviews the physiologic changes that occur during and after convulsive seizures and how these may contribute to SUDEP. Seizures activate specific cortical and subcortical regions that can cause potentially lethal cardiorespiratory changes. Clinical factors, including sleep state, medication treatment and withdrawal, positioning and posturing during seizures, and underlying structural or genetic conditions may also affect specific aspects of seizures that may contribute to SUDEP. While seizure control, either through medication or surgical treatment, is the primary intervention that reduces SUDEP risk, unfortunately, seizures cannot be fully controlled despite maximal treatment in a significant proportion of people with epilepsy. Thus specific interventions to prevent adverse seizure-related cardiopulmonary consequences are needed. The potential roles of repositioning/stimulation after seizures, oxygen supplementation, cardiopulmonary resuscitation and clinical treatment options in reducing SUDEP risk are explored. Ultimately, understanding of these factors may lead to interventions that could reduce or prevent SUDEP.
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Affiliation(s)
- Maromi Nei
- Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America.
| | - Allyson Pickard
- Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America
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13
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Chan SW, Dervan LA, Watson RS, Anderson AE, Lai YC. Epilepsy duration is an independent factor for electrocardiographic changes in pediatric epilepsy. Epilepsia Open 2021; 6:588-596. [PMID: 34235879 PMCID: PMC8408606 DOI: 10.1002/epi4.12519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Cardiac alterations represent a potential epilepsy‐associated comorbidity. Whether cardiac changes occur as a function of epilepsy duration is not well understood. We sought to evaluate whether cardiac alterations represented a time‐dependent phenomenon in pediatric epilepsy. Methods We retrospectively followed pediatric epilepsy patients without preexisting cardiac conditions or ion channelopathies who had history of pediatric intensive care unit admission for convulsive seizures or status epilepticus between 4/2014 and 7/2017. All available 12‐lead electrocardiograms (ECGs) from these patients between 1/2006 and 5/2019 were included. We examined ECG studies for changes in rhythm; PR, QRS, or corrected QT intervals; QRS axis or morphology; ST segment; or T wave. Data were analyzed using multivariable models containing covariates associated with ECG changes or epilepsy duration from the univariate analyses. Results 127 children with 323 ECGs were included in the analyses. The median epilepsy duration was 3.9 years (IQR 1.3‐8.4 years) at the time of an ECG study and a median of 2 ECGs (IQR 1‐3) per subject. The clinical encounters associated with ECGs ranged from well‐child visits to status epilepticus. We observed changes in 171 ECGs (53%), with 83 children (65%) had at least 1 ECG with alterations. In a multivariable logistic regression model adjusting for potentially confounding variables and accounting for clustering by patient, epilepsy duration was independently associated with altered ECGs for each year of epilepsy (OR: 1.1, 95% CI: 1.0‐1.2, P = .002). Extrapolating from this model, children with epilepsy durations of 10 and 15 years had 2.9 and 4.9 times the odds of having ECG changes, respectively. Significance Cardiac alterations may become more common with increasing epilepsy duration in select pediatric epilepsy patients. Future studies are needed to determine the potential clinical implications and the generalizability of these observations.
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Affiliation(s)
- See Wai Chan
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Leslie A Dervan
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Robert Scott Watson
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Anne E Anderson
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Yi-Chen Lai
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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14
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You SM, Jo HJ, Cho BH, Song JY, Kim DY, Hwang YH, Shon YM, Seo DW, Kim IY. Comparing Ictal Cardiac Autonomic Changes in Patients with Frontal Lobe Epilepsy and Temporal Lobe Epilepsy by Ultra-Short-Term Heart Rate Variability Analysis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:666. [PMID: 34203291 PMCID: PMC8304923 DOI: 10.3390/medicina57070666] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Abnormal epileptic discharges in the brain can affect the central brain regions that regulate autonomic activity and produce cardiac symptoms, either at onset or during propagation of a seizure. These autonomic alterations are related to cardiorespiratory disturbances, such as sudden unexpected death in epilepsy. This study aims to investigate the differences in cardiac autonomic function between patients with temporal lobe epilepsy (TLE) and frontal lobe epilepsy (FLE) using ultra-short-term heart rate variability (HRV) analysis around seizures. Materials and Methods: We analyzed electrocardiogram (ECG) data recorded during 309 seizures in 58 patients with epilepsy. Twelve patients with FLE and 46 patients with TLE were included in this study. We extracted the HRV parameters from the ECG signal before, during and after the ictal interval with ultra-short-term HRV analysis. We statistically compared the HRV parameters using an independent t-test in each interval to compare the differences between groups, and repeated measures analysis of variance was used to test the group differences in longitudinal changes in the HRV parameters. We performed the Tukey-Kramer multiple comparisons procedure as the post hoc test. Results: Among the HRV parameters, the mean interval between heartbeats (RRi), normalized low-frequency band power (LF) and LF/HF ratio were statistically different between the interval and epilepsy types in the t-test. Repeated measures ANOVA showed that the mean RRi and RMSSD were significantly different by epilepsy type, and the normalized LF and LF/HF ratio significantly interacted with the epilepsy type and interval. Conclusions: During the pre-ictal interval, TLE patients showed an elevation in sympathetic activity, while the FLE patients showed an apparent increase and decrease in sympathetic activity when entering and ending the ictal period, respectively. The TLE patients showed a maintained elevation of sympathetic and vagal activity in the pos-ictal interval. These differences in autonomic cardiac characteristics between FLE and TLE might be relevant to the ictal symptoms which eventually result in SUDEP.
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Affiliation(s)
- Sung-Min You
- Department of Biomedical Engineering, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea;
| | - Hyun-Jin Jo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Baek-Hwan Cho
- Medical AI Research Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea;
- Department of Medical Device Management and Research, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo-Yeon Song
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Dong-Yeop Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Yoon-Ha Hwang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Young-Min Shon
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - Dae-Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Korea; (H.-J.J.); (J.-Y.S.); (D.-Y.K.); (Y.-H.H.); (Y.-M.S.)
| | - In-Young Kim
- Department of Biomedical Engineering, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea;
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15
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Ochoa-Urrea M, Lacuey N, Vilella L, Zhu L, Jamal-Omidi S, Rani MRS, Hampson JP, Dayyani M, Hampson J, Hupp NJ, Tao S, Sainju RK, Friedman D, Nei M, Scott C, Allen L, Gehlbach BK, Reick-Mitrisin V, Schuele S, Ogren J, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Zhang GQ, Lhatoo SD. Seizure Clusters, Seizure Severity Markers, and SUDEP Risk. Front Neurol 2021; 12:643916. [PMID: 33643216 PMCID: PMC7907515 DOI: 10.3389/fneur.2021.643916] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Rationale: Seizure clusters may be related to Sudden Unexpected Death in Epilepsy (SUDEP). Two or more generalized convulsive seizures (GCS) were captured during video electroencephalography in 7/11 (64%) patients with monitored SUDEP in the MORTEMUS study. It follows that seizure clusters may be associated with epilepsy severity and possibly with SUDEP risk. We aimed to determine if electroclinical seizure features worsen from seizure to seizure within a cluster and possible associations between GCS clusters, markers of seizure severity, and SUDEP risk. Methods: Patients were consecutive, prospectively consented participants with drug-resistant epilepsy from a multi-center study. Seizure clusters were defined as two or more GCS in a 24-h period during the recording of prolonged video-electroencephalography in the Epilepsy monitoring unit (EMU). We measured heart rate variability (HRV), pulse oximetry, plethysmography, postictal generalized electroencephalographic suppression (PGES), and electroencephalography (EEG) recovery duration. A linear mixed effects model was used to study the difference between the first and subsequent seizures, with a level of significance set at p < 0.05. Results: We identified 112 GCS clusters in 105 patients with 285 seizures. GCS lasted on average 48.7 ± 19 s (mean 49, range 2-137). PGES emerged in 184 (64.6%) seizures and postconvulsive central apnea (PCCA) was present in 38 (13.3%) seizures. Changes in seizure features from seizure to seizure such as seizure and convulsive phase durations appeared random. In grouped analysis, some seizure features underwent significant deterioration, whereas others improved. Clonic phase and postconvulsive central apnea (PCCA) were significantly shorter in the fourth seizure compared to the first. By contrast, duration of decerebrate posturing and ictal central apnea were longer. Four SUDEP cases in the cluster cohort were reported on follow-up. Conclusion: Seizure clusters show variable changes from seizure to seizure. Although clusters may reflect epilepsy severity, they alone may be unrelated to SUDEP risk. We suggest a stochastic nature to SUDEP occurrence, where seizure clusters may be more likely to contribute to SUDEP if an underlying progressive tendency toward SUDEP has matured toward a critical SUDEP threshold.
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Affiliation(s)
- Manuela Ochoa-Urrea
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nuria Lacuey
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Laura Vilella
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Liang Zhu
- Biostatistics & Epidemiology Research Design Core, Division of Clinical and Translational Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Shirin Jamal-Omidi
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - M R Sandhya Rani
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Johnson P Hampson
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mojtaba Dayyani
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jaison Hampson
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Norma J Hupp
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Shiqiang Tao
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rup K Sainju
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Daniel Friedman
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University Langone School of Medicine, New York, NY, United States
| | - Maromi Nei
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Catherine Scott
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Luke Allen
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Brian K Gehlbach
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | | | - Stephan Schuele
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jennifer Ogren
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Ronald M Harper
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Beate Diehl
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Lisa M Bateman
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Orrin Devinsky
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University Langone School of Medicine, New York, NY, United States
| | - George B Richerson
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Guo-Qiang Zhang
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Samden D Lhatoo
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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16
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Kulju T, Verner R, Dibué-Adjei M, Eronen A, Rainesalo S, Lehtimäki K, Haapasalo J, Peltola J. Circadian distribution of autostimulations in rVNS therapy in patients with refractory focal epilepsy. Epilepsy Behav 2020; 110:107144. [PMID: 32473521 DOI: 10.1016/j.yebeh.2020.107144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/17/2020] [Accepted: 04/24/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Responsive vagus nerve stimulation (rVNS) utilizes an electrocardiograph (ECG)-based algorithm to detect rapid sympathetic activations associated with the onset of a seizure. Abrupt sympathetic activation may also be associated with nocturnal arousals between sleep cycles or transitioning from sleep to wakefulness, a period in which many patients with epilepsy experience seizures. Because of circadian changes in autonomic function, we hypothesized that the autostimulation feature might also behave in a circadian fashion. OBJECTIVE The aim of this study was to assess the circadian rhythmicity of autostimulations in rVNS treatment in patients with drug-resistant epilepsy (DRE). MATERIALS AND METHODS We performed a retrospective follow-up study of 30 patients with DRE treated with rVNS including 17 new implantations and 13 battery replacements at a single center in Finland. After initiation of autostimulation mode, the exact rVNS stimulation parameters and the timestamps of all individual autostimulations delivered were registered. A clustered autostimulation was defined as any autostimulation that occurred within the duration of the therapeutic cycle during the therapy "OFF" time compared with both the previous autostimulation and the following autostimulation. RESULTS Autostimulations and especially autostimulation clusters show a higher probability of occurring in the morning and less at night. This trend appeared to follow the circadian rhythm of cortisol concentration. CONCLUSIONS Early morning peaks of autostimulations at low thresholds may reflect awakening-induced activation of the cardiovascular system, which is associated with a shift towards the dominance of the sympathetic branch of the autonomic nervous system. Cortisol release occurs in parallel driven by wakening-induced activation of the hypothalamic-pituitary-adrenal axis, which is fine-tuned by direct sympathetic input to the adrenal gland. This is of interest considering the known sympathetic hyperactivity in patients with epilepsy.
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Affiliation(s)
- Toni Kulju
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, Tampere FI-33521, Finland; Tampere University, Faculty of Medicine and Health Technology, FI-33014 Tampere, Finland.
| | - Ryan Verner
- LivaNova USA, Neuromodulation Unit, 100 Cyberonics Blvd, Houston, TX 77058, USA
| | - Maxine Dibué-Adjei
- Neuromodulation Medical Affairs, LivaNova PLC,London, United Kingdom; Department of Neurosurgery, Heinrich Heine University Düsseldorf, Germany
| | - Atte Eronen
- Tampere University, Faculty of Medicine and Health Technology, FI-33014 Tampere, Finland
| | - Sirpa Rainesalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, Tampere FI-33521, Finland
| | - Kai Lehtimäki
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, Tampere FI-33521, Finland
| | - Joonas Haapasalo
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, Tampere FI-33521, Finland; The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, Ontario M5G 0A4, Canada
| | - Jukka Peltola
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, P.O. Box 2000, Tampere FI-33521, Finland; Tampere University, Faculty of Medicine and Health Technology, FI-33014 Tampere, Finland
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17
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Borowicz-Reutt KK, Banach M, Rudkowska M. Nebivolol attenuates the anticonvulsant action of carbamazepine and phenobarbital against the maximal electroshock-induced seizures in mice. Pharmacol Rep 2020; 72:80-86. [PMID: 32016836 PMCID: PMC8163711 DOI: 10.1007/s43440-019-00029-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/08/2019] [Accepted: 09/05/2019] [Indexed: 01/13/2023]
Abstract
Background Due to co-occurrence of seizures and cardiovascular disorders, nebivolol, a widely used selective β1-blocker with vasodilatory properties, may be co-administered with antiepileptic drugs. Therefore, we wanted to assess interactions between nebivolol and four conventional antiepileptic drugs: carbamazepine, valproate, phenytoin and phenobarbital in the screening model of tonic–clonic convulsions. Methods Seizure experiments were conducted in the electroconvulsive threshold and maximal electroshock tests in mice. The chimney test served as a method of assessing motor coordination, whereas long-term memory was evaluated in the computerized step-through passive-avoidance task. To exclude or confirm pharmacokinetic interactions, we measured brain concentrations of antiepileptic drugs using the fluorescence polarization immunoassay. Results It was shown that nebivolol applied at doses 0.5–15 mg/kg did not raise the threshold for electroconvulsions. However, nebivolol at the dose of 15 mg/kg reduced the anti-electroshock properties of carbamazepine. The effect of valproate, phenytoin, and phenobarbital remained unchanged by combination with the β-blocker. Nebivolol significantly decreased the brain concentration of valproate, but did not affect concentrations of remaining antiepileptic drugs. Therefore, contribution of pharmacokinetic interactions to the final effect of the nebivolol/carbamazepine combination seems not probable. Nebivolol alone and in combinations with antiepileptic drugs did not impair motor performance in mice. Nebivolol alone did not affect long-term memory of animals, and did not potentiate memory impairment induced by valproate and carbamazepine. Conclusions This study indicates that nebivolol attenuated effectiveness of some antiepileptic drugs. In case the results are confirmed in clinical settings, this β-blocker should be used with caution in epileptic patients.
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Affiliation(s)
- Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland.
| | - Monika Banach
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland
| | - Monika Rudkowska
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Jaczewskiego 8, PL-20-954, Lublin, Poland
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18
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Elnazeir M, Badugu P, Narayanan S, Hussain A, Bhagat RN, Jones CM, Holiday VN, Evans MS, Palade AE. Generalized tonic-clonic seizures with post-ictal atrial fibrillation. Epilepsy Behav Rep 2019; 13:100343. [PMID: 32322817 PMCID: PMC7170332 DOI: 10.1016/j.ebr.2019.100343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/18/2019] [Accepted: 10/27/2019] [Indexed: 12/31/2022] Open
Abstract
Convulsive seizures are known to cause severe cardiopulmonary changes and increased autonomic activity. Limited reports describe peri-ictal cardiac arrhythmias such as atrial fibrillation (AF) with generalized tonic–clonic seizures (GTCS). We present a unique case of a healthy 23-year-old male patient with new onset prolonged AF in the setting of new onset seizures, occurring on three independent occasions. Over two years, our patient had multiple hospitalizations for seizures with an electrocardiogram (ECG) diagnosis of AF made on three different occasions, occurring during his post-ictal state (all within 30 min of seizure onset). These seizures were never captured by electroencephalography (EEG) or witnessed by the medical staff, but were reported by family and/or reviewed on video provided by them. After his first GTCS, his AF persisted and was medically cardioverted. Two additional instances of AF after witnessed GTCS have been captured. After his second unprovoked seizure, an anti-seizure drug (ASD) was prescribed. A multi-disciplinary approach may be adopted to address comorbidities associated with seizures. Aggressive evaluation and treatment should be employed for newly diagnosed and refractory seizure patients associated with arrhythmias, in our case AF. Peri-ictal arrhythmias may be considered a potential marker for increased sudden unexpected death in epilepsy (SUDEP) risk. Association of new onset post-ictal atrial fibrillation (AF) with new onset generalized tonic-clonic seizure (GTCS) is rare Over a two year period, an overall healthy 23-year-old male was found to have three independent AF occurrences after GTCS A multi-disciplinary approach and aggressive treatment with anti-seizure drugs may be adopted to address such events
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Affiliation(s)
- Marwa Elnazeir
- Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA
| | - Pradeepthi Badugu
- Department of Medicine, University of Louisville, 501 East Broadway, Suite 100, Louisville, KY 40202, USA
| | - Siddharth Narayanan
- Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40202, USA
| | - Abid Hussain
- Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40202, USA
| | - Riwaj N.M.N. Bhagat
- Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA
| | - Christopher M. Jones
- Department of Surgery, University of Louisville, 550 South Jackson Street, Louisville, KY 40202, USA
| | - Victoria N. Holiday
- Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA
| | - Miles S. Evans
- Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA
| | - Adriana E. Palade
- Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA
- Corresponding author at: Department of Neurology, University of Louisville, 500 South Jackson Street, Louisville, KY 40202, USA.
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19
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Elmali AD, Bebek N, Baykan B. Let's talk SUDEP. ACTA ACUST UNITED AC 2019; 56:292-301. [PMID: 31903040 DOI: 10.29399/npa.23663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/21/2019] [Indexed: 01/17/2023]
Abstract
Sudden unexplained death in epilepsy (SUDEP) is a devastating complication of epilepsy which was under-recognized in the recent past despite its clear importance. In this review, we examine the definition of SUDEP, revise current pathophysiological theories, discuss risk factors and preventative measures, disclose tools for appraising the SUDEP risk, and last but not least dwell upon announcing and explaining the SUDEP risk to the patients and their caretakers. We aim to aid the clinicians in their responsibility of knowing SUDEP, explaining the SUDEP risk to their patients in a reasonable and sensible way and whenever possible, preventing SUDEP. Future studies are definitely needed to increase scientific knowledge and awareness related to this prioritized topic with malign consequences.
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Affiliation(s)
- Ayşe Deniz Elmali
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
| | - Nerses Bebek
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
| | - Betül Baykan
- İstanbul University, İstanbul Faculty of Medicine, Department of Neurology, İstanbul, Turkey
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20
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Repeated generalized seizures can produce calcified cardiac lesions in DBA/1 mice. Epilepsy Behav 2019; 95:169-174. [PMID: 31063933 DOI: 10.1016/j.yebeh.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 04/08/2019] [Accepted: 04/08/2019] [Indexed: 12/14/2022]
Abstract
Studies suggest that cardiorespiratory dysfunction likely contributes to sudden unexpected death in epilepsy (SUDEP). Seizures result in autonomic and respiratory dysfunction, leading to sympathetic hyperactivity and respiratory distress, including apnea. While the heart is vulnerable to catecholamine surges and hypoxia, it remains unknown if repetitive generalized seizures lead to cardiac damage. DBA/1 mice exhibit seizure-induced respiratory arrest (S-IRA) following generalized audiogenic seizures (AGS), which can be resuscitated using a rodent ventilator. In the current study, we induced different numbers of S-IRA episodes in DBA/1 mice and determined the association of repeated S-IRA induction with cardiac damage using histology. After repetitive induction of 18 S-IRA, calcified lesions, as revealed by calcium (Ca2+)-specific alizarin red staining, were observed in the ventricular myocardium in 61.5% of DBA/1 mice, which was higher compared to mice with 5 S-IRA and 1 S-IRA as well as age-matched untested control mice. The incidence of lesions in mice with 9 S-IRA was only higher than that of control mice. Only 1-2, small lesions were observed in mice with 5 S-IRA and 1 S-IRA and in control mice. Larger lesions (>2500 μm2) were observed in mice with 9 and 18 S-IRA. The incidence of larger lesions was higher in mice with 18 S-IRA (53.8%) as compared to mice with 5 S-IRA and 1 S-IRA as well as with control mice, and the incidence of larger lesions in mice with 9 S-IRA was only higher than that of control mice. Repeated induction of S-IRA in DBA/1 mice can result in calcified necrotic lesions in the ventricles of the heart, and their incidence and size are dependent on the total number of S-IRA.
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21
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Nass RD, Hampel KG, Elger CE, Surges R. Blood Pressure in Seizures and Epilepsy. Front Neurol 2019; 10:501. [PMID: 31139142 PMCID: PMC6527757 DOI: 10.3389/fneur.2019.00501] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/25/2019] [Indexed: 12/18/2022] Open
Abstract
In this narrative review, we summarize the current knowledge of neurally mediated blood pressure (BP) control and discuss how recently described epilepsy- and seizure-related BP alterations may contribute to premature mortality and sudden unexpected death in epilepsy (SUDEP). Although people with epilepsy display disturbed interictal autonomic function with a shift toward predominant sympathetic activity, prevalence of arterial hypertension is similar in people with and without epilepsy. BP is transiently increased in association with most types of epileptic seizures but may also decrease in some, illustrating that seizure activity can cause both a decrease and increase of BP, probably because of stimulation or inhibition of distinct central autonomic function by epileptic activity that propagates into different neuronal networks of the central autonomic nervous system. The principal regulatory neural loop for short-term BP control is termed baroreflex, mainly involving peripheral sensors and brain stem nuclei. The baroreflex sensitivity (BRS, expressed as change of interbeat interval per change in BP) is intact after focal seizures, whereas BRS is markedly impaired in the early postictal period following generalized convulsive seizures (GCS), possibly due to metabolically mediated muscular hyperemia in skeletal muscles, a massive release of catecholamines and compromised brain stem function. Whilst most SUDEP cases are probably caused by a cardiorespiratory failure during the early postictal period following GCS, a profoundly disturbed BRS may allow a life-threatening drop of systemic BP in the aftermath of GCS, as recently reported in a patient as a plausible cause of SUDEP in a few patients.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Kevin G Hampel
- Department of Neurology, University Hospital La Fe, Valencia, Spain
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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22
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DeGiorgio CM, Curtis A, Hertling D, Moseley BD. Sudden unexpected death in epilepsy: Risk factors, biomarkers, and prevention. Acta Neurol Scand 2019; 139:220-230. [PMID: 30443951 DOI: 10.1111/ane.13049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 01/01/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is one of the most important direct epilepsy-related causes of death, with an incidence in adults of 1.2 per 1000 person-years. Generalized tonic-clonic seizures have consistently emerged as the leading risk factor for SUDEP, particularly when such seizures are uncontrolled. High seizure burden, lack of antiepileptic drug (AED) treatment, polytherapy, intellectual disability, and prone position at the time of death are other key risk factors. Unfortunately, despite advances in treatment, overall mortality rates in epilepsy are rising. It is imperative that we learn more about SUDEP so that effective prevention strategies can be implemented. To help identify persons at greater risk of SUDEP and in need of closer monitoring, biomarkers are needed. Candidate biomarkers include electrocardiographic, electroencephalographic, and imaging abnormalities observed more frequently in those who have died suddenly and unexpectedly. As our knowledge of the pathophysiologic mechanisms behind SUDEP has increased, various preventative measures have been proposed. These include lattice pillows, postictal oxygen therapy, selective serotonin reuptake inhibitors, and inhibitors of opiate and adenosine receptors. Unfortunately, no randomized clinical trials are available to definitively conclude these measures are effective. Rather, gaining the best control of seizures possible (with AEDs, devices, and resective surgery) still remains the intervention with the best evidence to reduce the risk of SUDEP. In this evidence-based review, we explore the incidence of SUDEP and review the risk factors, biomarkers, and latest prevention strategies.
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Affiliation(s)
| | - Ashley Curtis
- Undergraduate Interdepartmental Program for Neuroscience, UCLA Los Angeles California
| | - Dieter Hertling
- Undergraduate Interdepartmental Program for Neuroscience, UCLA Los Angeles California
| | - Brian D. Moseley
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati Ohio
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23
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Nass RD, Motloch LJ, Paar V, Lichtenauer M, Baumann J, Zur B, Hoppe UC, Holdenrieder S, Elger CE, Surges R. Blood markers of cardiac stress after generalized convulsive seizures. Epilepsia 2019; 60:201-210. [PMID: 30645779 DOI: 10.1111/epi.14637] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Generalized convulsive seizures (GCS) are associated with high demands on the cardiovascular system, thereby facilitating cardiac complications. To investigate occurrence, influencing factors, and extent of cardiac stress or injury, the alterations and time course of the latest generation of cardiac blood markers were investigated after documented GCS. METHODS Adult patients with refractory epilepsy who underwent video-electroencephalography (EEG) monitoring along with simultaneous one-lead electrocardiography (ECG) recordings were included. Cardiac biomarkers (cardiac troponin I [cTNI]; high-sensitive troponin T [hsTNT]; N-terminal prohormone of brain natriuretic peptide [NT-proBNP]; copeptin; suppression of tumorigenicity-2 [SST-2]; growth differentiation factor 15, [GDF-15]; soluble urokinase plasminogen activator receptor [suPAR]; and heart-type fatty acid binding protein [HFABP]) and catecholamines were measured at inclusion and at different time points after GCS. Periictal cardiac properties were assessed by analyzing heart rate (HR), HR variability (HRV), and corrected QT intervals(QTc). RESULTS Thirty-six GCS (6 generalized-onset tonic-clonic seizures and 30 focal to bilateral tonic-clonic seizures) were recorded in 30 patients without a history of cardiac or renal disease. Postictal catecholamine levels were elevated more than twofold. A concomitant increase in HR and QTc, as well as a decrease in HRV, was observed. Elevations of cTNI and hsTNT were found in 3 of 30 patients (10%) and 6 of 23 patients (26%), respectively, which were associated with higher dopamine levels. Copeptin was increased considerably after most GCS, whereas SST-2, HFABP, and GDF-15 displayed only subtle variations, and suPAR was unaltered in the postictal period. Cardiac symptoms did not occur in any patient. SIGNIFICANCE The use of more sensitive biomarkers such as hsTNT suggests that signs of cardiac stress occur in about 25% of the patients with GCS without apparent clinical symptoms. SuPAR may indicate clinically relevant troponin elevations. Copeptin could help to diagnose GCS, but specificity needs to be tested.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Lukas J Motloch
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Vera Paar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Jan Baumann
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Berndt Zur
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn Medical Center, Bonn, Germany
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Stefan Holdenrieder
- Institute for Clinical Chemistry and Clinical Pharmacology, University of Bonn Medical Center, Bonn, Germany.,Institute for Laboratory Medicine, German Heart Center Munich, Technical University, Munich, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany.,Section of Epileptology, Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
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24
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Mamalyga ML, Mamalyga LM. [The effect of status epilepticus on autonomic regulation of the heart and its functional capabilities in different postictal periods]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:48-54. [PMID: 32207731 DOI: 10.17116/jnevro201911911248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To study the postictal changes in the autonomic regulation of the heart rhythm and its functional capabilities in different periods after epistatus and to assess the risk of life-threatening arrhythmias. MATERIAL AND METHODS The study was conducted on Wistar rats after epileptic status (ES). Telemonitoring of EEG and ECG was performed in the online mode using the system of the company 'ADInstruments'. Functional stress test with dobutamine was used. RESULTS ES leads to a long-lasting disturbance of autonomic regulation (AR) of the heart and reduces its functional capabilities. The heart's AR balance is shifted towards sympathetic tonus 5 days after ES. This increases the predictors of life-threatening arrhythmias. The decrease in SWD activity increases the activity of parasympathetic tonus 10 days after ES. However, this is due to the tension of regulation mechanisms and the risk of life-threatening arrhythmias. CONCLUSION The high degree of seizure activity of the brain in the ES predetermines prolonged postictal disorders of the AR heart, which reduce its functional capabilities and increase the risk of life-threatening arrhythmias.
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Affiliation(s)
- M L Mamalyga
- Bakulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia
| | - L M Mamalyga
- Institute of biology and chemistry of Moscow Pedagogical State University, Moscow, Russia
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25
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Purnell BS, Thijs RD, Buchanan GF. Dead in the Night: Sleep-Wake and Time-Of-Day Influences on Sudden Unexpected Death in Epilepsy. Front Neurol 2018; 9:1079. [PMID: 30619039 PMCID: PMC6297781 DOI: 10.3389/fneur.2018.01079] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/27/2018] [Indexed: 11/13/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death in patients with refractory epilepsy. Convergent lines of evidence suggest that SUDEP occurs due to seizure induced perturbation of respiratory, cardiac, and electrocerebral function as well as potential predisposing factors. It is consistently observed that SUDEP happens more during the night and the early hours of the morning. The aim of this review is to discuss evidence from patient cases, clinical studies, and animal research which is pertinent to the nocturnality of SUDEP. There are a number of factors which might contribute to the nighttime predilection of SUDEP. These factors fall into four categories: influences of (1) being unwitnessed, (2) lying prone in bed, (3) sleep-wake state, and (4) circadian rhythms. During the night, seizures are more likely to be unwitnessed; therefore, it is less likely that another person would be able to administer a lifesaving intervention. Patients are more likely to be prone on a bed following a nocturnal seizure. Being prone in the accouterments of a bed during the postictal period might impair breathing and increase SUDEP risk. Sleep typically happens at night and seizures which emerge from sleep might be more dangerous. Lastly, there are circadian changes to physiology during the night which might facilitate SUDEP. These possible explanations for the nocturnality of SUDEP are not mutually exclusive. The increased rate of SUDEP during the night is likely multifactorial involving both situational factors, such as being without a witness and prone, and physiological changes due to the influence of sleep and circadian rhythms. Understanding the causal elements in the nocturnality of SUDEP may be critical to the development of effective preventive countermeasures.
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Affiliation(s)
- Benton S Purnell
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.,Neuroscience Program, University of Iowa, Iowa City, IA, United States.,Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom.,Department of Neurology, LUMC Leiden University Medical Center, Leiden, Netherlands
| | - Gordon F Buchanan
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.,Neuroscience Program, University of Iowa, Iowa City, IA, United States.,Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
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26
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Autonomic aspects of sudden unexpected death in epilepsy (SUDEP). Clin Auton Res 2018; 29:151-160. [DOI: 10.1007/s10286-018-0576-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/07/2018] [Indexed: 12/25/2022]
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27
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Yang Z, Liu H, Meng F, Guan Y, Zhao M, Qu W, Hao H, Luan G, Zhang J, Li L. The analysis of circadian rhythm of heart rate variability in patients with drug-resistant epilepsy. Epilepsy Res 2018; 146:151-159. [DOI: 10.1016/j.eplepsyres.2018.08.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 07/17/2018] [Accepted: 08/06/2018] [Indexed: 01/01/2023]
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28
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Esmaeili B, Kaffashi F, Theeranaew W, Dabir A, Lhatoo SD, Loparo KA. Post-ictal Modulation of Baroreflex Sensitivity in Patients With Intractable Epilepsy. Front Neurol 2018; 9:793. [PMID: 30319527 PMCID: PMC6168624 DOI: 10.3389/fneur.2018.00793] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/03/2018] [Indexed: 11/20/2022] Open
Abstract
Objective: Seizure-related autonomic dysregulation occurs in epilepsy patients and may contribute to Sudden Unexpected Death in Epilepsy (SUDEP). We tested how different types of seizures affect baroreflex sensitivity (BRS) and heart rate variability (HRV). We hypothesized that BRS and HRV would be reduced after bilateral convulsive seizures (BCS). Methods: We recorded blood pressure (BP), electrocardiogram (ECG) and oxygen saturation continuously in patients (n = 18) with intractable epilepsy undergoing video-EEG monitoring. A total of 23 seizures, either focal seizures (FS, n = 14) or BCS (n = 9), were analyzed from these patients. We used 5 different HRV measurements in both the time and frequency domains to study HRV in pre- and post-ictal states. We used the average frequency domain gain, computed as the average of the magnitude ratio between the systolic BP (BPsys) and the RR-interval time series, in the low-frequency (LF) band as frequency domain index of BRS in addition to the instantaneous slope between systolic BP and RR-interval satisfying spontaneous BRS criteria as a time domain index of BRS. Results: Overall, the post-ictal modulation of HRV varied across the subjects but not specifically by the type of seizures. Comparing pre- to post-ictal epochs, the LF power of BRS decreased in 8 of 9 seizures for patients with BCS; whereas following 12 of 14 FS, BRS increased. Similarly, spontaneous BRS decreased following 7 of 9 BCS. The presence or absence of oxygen desaturation was not consistent with the changes in BRS following seizures, and the HRV does not appear to be correlated with the BRS changes. These data suggest that a transient decrease in BRS and temporary loss of cardiovascular homeostatic control can follow BCS but is unlikely following FS. Significance: These findings indicate significant post-ictal autonomic dysregulation in patients with epilepsy following BCS. Further, reduced BRS following BCS, if confirmed in future studies on SUDEP cases, may indicate one quantifiable risk marker of SUDEP.
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Affiliation(s)
- Behnaz Esmaeili
- Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Farhad Kaffashi
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Wanchat Theeranaew
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
| | - Aman Dabir
- Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Samden D Lhatoo
- Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Kenneth A Loparo
- Department of Electrical Engineering and Computer Science, Case School of Engineering, Case Western Reserve University, Cleveland, OH, United States
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29
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Kommajosyula SP, Tupal S, Faingold CL. Deficient post-ictal cardiorespiratory compensatory mechanisms mediated by the periaqueductal gray may lead to death in a mouse model of SUDEP. Epilepsy Res 2018; 147:1-8. [PMID: 30165263 DOI: 10.1016/j.eplepsyres.2018.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/20/2018] [Accepted: 08/18/2018] [Indexed: 11/17/2022]
Abstract
Post-ictal cardiorespiratory failure is implicated as a major cause of sudden unexpected death in epilepsy (SUDEP) in patients. The DBA/1 mouse model of SUDEP is abnormally susceptible to fatal seizure-induced cardiorespiratory failure (S-CRF) induced by convulsant drug, hyperthermia, electroshock, and acoustic stimulation. Clinical and pre-clinical studies have implicated periaqueductal gray (PAG) abnormalities in SUDEP. Recent functional neuroimaging studies observed that S-CRF resulted in selective changes in PAG neuronal activity in DBA/1 mice. The PAG plays a critical compensatory role for respiratory distress caused by numerous physiological challenges in non-epileptic individuals. These observations suggest that abnormalities in PAG-mediated cardiorespiratory modulation may contribute to S-CRF in DBA/1 mice. To evaluate this, electrical stimulation (20 Hz, 20-100 μA, 10 s) was presented in the PAG of anesthetized DBA/1 and C57BL/6 (non-epileptic) control mice, and post-stimulus changes in respiration [inter-breath interval (IBI)] and heart rate variability (HRV) were examined. The post-stimulus period was considered analogous to the post-ictal period when S-CRF occurred in previous DBA/1 mouse studies. PAG stimulation caused significant intensity-related decreases in IBI in both mouse strains. However, this effect was significantly reduced in DBA/1 vis-a-vis C57BL/6 mice. These changes began immediately following cessation of stimulation and remained significant for 10 s. This time period is critical for initiating resuscitation to successfully prevent seizure-induced death in previous DBA/1 mouse experiments. Significant post-stimulus increases in HRV were also seen at ≥60 μA in the PAG in C57BL/6 mice, which were absent in DBA/1 mice. These data along with previous neuroimaging findings suggest that compensatory cardiorespiratory modulation mediated by PAG is deficient, which may be important to the susceptibility of DBA/1 mice to S-CRF. These observations suggest that correcting this deficit pharmacologically or by electrical stimulation may help to prevent S-CRF. These findings further support the potential importance of PAG abnormalities to human SUDEP.
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Affiliation(s)
- Srinivasa P Kommajosyula
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, PO BOX 19629, Springfield, IL, 62794-9629, United States
| | - Srinivasan Tupal
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, PO BOX 19629, Springfield, IL, 62794-9629, United States
| | - Carl L Faingold
- Departments of Pharmacology and Neurology, Southern Illinois University School of Medicine, PO BOX 19629, Springfield, IL, 62794-9629, United States.
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30
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Stewart M. An explanation for sudden death in epilepsy (SUDEP). J Physiol Sci 2018; 68:307-320. [PMID: 29542031 PMCID: PMC10717429 DOI: 10.1007/s12576-018-0602-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/06/2018] [Indexed: 01/02/2023]
Abstract
This review traces the examination of autonomic, cardiovascular, and respiratory derangements associated with seizure activity in the clinical and preclinical literature generally, and in the author's animal model specifically, and concludes with the author's views on the potential mechanisms for sudden death in epilepsy (SUDEP). An animal model that employs kainic acid-induced seizures on a background of urethane anesthesia has permitted unprecedented access to the behavior of autonomic, cardiovascular, and respiratory systems during seizure activity. The result is a detailed description of the major causes of death and how this animal model can be used to develop and test preventative and interventional strategies. A critical translational step was taken when the rat data were shown to directly parallel data from definite SUDEP cases in the clinical literature. The reasons why ventricular fibrillation as a cause of death is so rarely reported and tools for verifying that seizure-associated laryngospasm can induce obstructive apnea as a cause of death are discussed in detail. Many details of the specific kinetics of activation of brainstem neurons serving autonomic and respiratory function remain to be elucidated, but the boundary conditions described in this review provide an excellent framework for more focused studies. A number of studies conducted in animal models of seizure activity and in epilepsy patients have contributed information on the autonomic, cardiovascular, and respiratory consequences of seizure activity spreading through hypothalamus and brainstem to the periphery. The result is detailed information on the systemic impact of seizure spread and the development of an understanding of the essential mechanistic features of sudden unexpected death in epilepsy (SUDEP). This review summarizes translation of data obtained from animal models to biomarkers that are useful in evaluating data from epilepsy patients.
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Affiliation(s)
- Mark Stewart
- Department of Physiology and Pharmacology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
- Department of Neurology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
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31
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Lai YC, Li N, Lawrence W, Wang S, Levine A, Burchhardt DM, Pautler RG, Valderrábano M, Wehrens XH, Anderson AE. Myocardial remodeling and susceptibility to ventricular tachycardia in a model of chronic epilepsy. Epilepsia Open 2018; 3:213-223. [PMID: 29881800 PMCID: PMC5983128 DOI: 10.1002/epi4.12107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 01/08/2023] Open
Abstract
Objective Sympathetic predominance and ventricular repolarization abnormalities represent epilepsy‐associated cardiac alterations and may underlie seizure‐induced ventricular arrhythmias. Myocardial ion channel and electrical remodeling have been described early in epilepsy development and may contribute to ventricular repolarization abnormalities and excitability. Using the pilocarpine‐induced acquired epilepsy model we sought to examine whether altered myocardial ion channel levels and electrophysiological changes also occur in animals with long‐standing epilepsy. Methods We examined myocardial adrenergic receptor and ion channel protein levels of epileptic and age‐matched sham rats (9–20 months old) using western blotting. Cardiac electrical properties were examined using optical mapping ex vivo and electrophysiology in vivo. We investigated the propensity for ventricular tachycardia (VT) and the effects of β‐adrenergic blockade on ventricular electrical properties and excitability in vivo. Results In animals with long‐standing epilepsy, we observed decreased myocardial voltage‐gated K+ channels Kv4.2 and Kv4.3, which are known to underlie early ventricular repolarization in rodents. Decreased β1 and increased α1A adrenergic receptor protein levels occurred in the myocardium of chronically epileptic animals consistent with elevated sympathetic tone. These animals exhibited many cardiac electrophysiological abnormalities, represented by longer QRS and corrected QT (QTc) intervals in vivo, slower conduction velocity ex vivo, and stimulation‐induced VT. Administration of a β‐adrenergic antagonist late in epilepsy was beneficial, as the therapy shortened the QTc interval and decreased stimulation‐induced VT. Significance Our findings demonstrate that myocardial ion channel remodeling and sympathetic predominance, risk factors for increased ventricular excitability and arrhythmias, persist in chronic epilepsy. The beneficial effects of β‐adrenergic antagonist treatment late in the course of epilepsy suggest that attenuating elevated sympathetic tone may represent a therapeutic target for ameliorating epilepsy‐associated cardiac morbidity.
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Affiliation(s)
- Yi-Chen Lai
- Department of Pediatrics Baylor College of Medicine Houston Texas U.S.A
| | - Na Li
- Department of Molecular Physiology and Biophysics Baylor College of Medicine Houston Texas U.S.A
| | - William Lawrence
- Department of Molecular Physiology and Biophysics Baylor College of Medicine Houston Texas U.S.A
| | - Sufen Wang
- DeBakey Heart and Vascular Center Methodist Hospital Research Institute Houston Texas U.S.A
| | - Amber Levine
- Department of Neuroscience Baylor College of Medicine Houston Texas U.S.A
| | | | - Robia G Pautler
- Department of Molecular Physiology and Biophysics Baylor College of Medicine Houston Texas U.S.A
| | - Miguel Valderrábano
- DeBakey Heart and Vascular Center Methodist Hospital Research Institute Houston Texas U.S.A
| | - Xander H Wehrens
- Department of Molecular Physiology and Biophysics Baylor College of Medicine Houston Texas U.S.A
| | - Anne E Anderson
- Department of Pediatrics Baylor College of Medicine Houston Texas U.S.A.,Department of Neuroscience Baylor College of Medicine Houston Texas U.S.A.,Department of Neurology Baylor College of Medicine Houston Texas U.S.A
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Middleton OL, Atherton DS, Bundock EA, Donner E, Friedman D, Hesdorffer DC, Jarrell HS, McCrillis AM, Mena OJ, Morey M, Thurman DJ, Tian N, Tomson T, Tseng ZH, White S, Wright C, Devinsky O. National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy. Acad Forensic Pathol 2018; 8:119-135. [PMID: 31240030 PMCID: PMC6474453 DOI: 10.23907/2018.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.
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Affiliation(s)
| | - Daniel S. Atherton
- University of Alabama at Birmingham, Anatomic Pathology, Division of Forensic Pathology
| | | | - Elizabeth Donner
- Comprehensive Epilepsy Program, The Hospital for Sick Children - Toronto
| | | | | | - Heather S. Jarrell
- University of New Mexico Health Sciences Center, Office of the Medical Investigator
| | | | | | | | | | - Niu Tian
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, Epilepsy Program
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institutet, Department of Neurology, Karolinska University Hospital
| | - Zian H. Tseng
- University of California, San Francisco, Cardiac Electrophysiology Section, Cardiology Division
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33
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Middleton O, Atherton D, Bundock E, Donner E, Friedman D, Hesdorffer D, Jarrell H, McCrillis A, Mena OJ, Morey M, Thurman D, Tian N, Tomson T, Tseng Z, White S, Wright C, Devinsky O. National Association of Medical Examiners position paper: Recommendations for the investigation and certification of deaths in people with epilepsy. Epilepsia 2018; 59:530-543. [PMID: 29492970 PMCID: PMC6084455 DOI: 10.1111/epi.14030] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/27/2022]
Abstract
Sudden unexpected death of an individual with epilepsy can pose a challenge to death investigators, as most deaths are unwitnessed, and the individual is commonly found dead in bed. Anatomic findings (eg, tongue/lip bite) are commonly absent and of varying specificity, thereby limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention constituted an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden unexpected death in a person with epilepsy is encountered.
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Affiliation(s)
- Owen Middleton
- Hennepin County Medical Examiner’s Office, Minneapolis, MN, USA
| | - Daniel Atherton
- Anatomic Pathology, Division of Forensic Pathology, Cooper Green Hospital, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Elizabeth Donner
- Comprehensive Epilepsy Program, Division of Neurology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel Friedman
- Department of Neurology, Langone Comprehensive Epilepsy Center, New York University, New York, NY, USA
| | - Dale Hesdorffer
- Gertrude H Sergievsky Center and Department of Epidemiology, Columbia University, New York, NY, USA
| | - Heather Jarrell
- Office of the Medical Investigator, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Aileen McCrillis
- New York University Langone Health, New York University School of Medicine, New York, NY, USA
| | - Othon J. Mena
- Ventura County Office of Chief Medical Examiner, Ventura, CA, USA
| | - Mitchel Morey
- Hennepin County Medical Examiner’s Office, Minneapolis, MN, USA
| | - David Thurman
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, USA
| | - Niu Tian
- Division of Population Health, Epilepsy Program, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Zian Tseng
- Cardiac Electrophysiology Section, Cardiology Division, University of California, San Francisco, San Francisco, CA, USA
| | - Steven White
- Office of the Medical Examiner, Cook County, Chicago, IL, USA
| | | | - Orrin Devinsky
- Department of Neurology, Langone Comprehensive Epilepsy Center, New York University, New York, NY, USA
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Kishk NA, Sharaf Y, Ebraheim AM, Baghdady Y, Alieldin N, Afify A, Eldamaty A. Interictal cardiac repolarization abnormalities in people with epilepsy. Epilepsy Behav 2018; 79:106-111. [PMID: 29274604 DOI: 10.1016/j.yebeh.2017.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/21/2017] [Accepted: 10/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The occurrence of cardiac electrical abnormalities such as repolarization disorders in patients with epilepsy was previously documented and may, in part, clarify the mechanism of sudden unexpected death in those patients. The aim of this study was to investigate the frequency of cardiac repolarization disorders among patients with epilepsy and whether specific demographic- or disease-related features were associated with their occurrence. SUBJECTS AND METHODS This cross-sectional study was carried out on 1000 subjects with epilepsy who were compared with age- and sex-matched 2500 subjects without epilepsy. Clinical assessment, which included careful history taking and examination, was carried out for all participants in addition to resting 12-lead electrocardiogram (ECG) recording. Electrocardiograms were reviewed by experienced cardiologists. Electrocardiogram intervals were measured, and morphological abnormalities were identified using standard guidelines. RESULTS Repolarization abnormalities were found in 142 (14.2%) patients with epilepsy. A statistically significant elevation in percentage of corrected QT interval (QTc) prolongation (both severe and borderline) among patients with epilepsy compared with controls was documented (8.4% vs 2%, P<0.001). Epilepsy increased the likelihood of hosting prolonged QTc more than 4 times (95% confidence interval: 3.175-6.515; odds ratio: 4.548; P<0.001). Affected patients were significantly older (95% confidence interval: 1.012-1.044; odds ratio: 1.027; P=0.001), and the abnormality was significantly more prevalent among those with poor seizure control (95% confidence interval: 1.103-2.966; odds ratio: 1.809; P=0.019). On the other hand, early repolarization (ER) pattern and Brugada type ECG pattern (BP) were significantly more prevalent in subjects without epilepsy. CONCLUSIONS Corrected QT interval prolongation (both severe and borderline) was more prevalent among patients with epilepsy, especially if uncontrolled or elderly. Electrocardiogram should be established as a part of the diagnostic workup of epilepsy in order to identify such electrocardiographic abnormality.
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Affiliation(s)
- Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Egypt
| | - Yasser Sharaf
- Cardiology Department, Faculty of Medicine, Cairo University, Egypt
| | - Asmaa M Ebraheim
- Neurology Department, Faculty of Medicine, Cairo University, Egypt.
| | - Yasser Baghdady
- Cardiology Department, Faculty of Medicine, Cairo University, Egypt
| | - Nelly Alieldin
- Cancer Epidemiology Department, National Cancer Institute, Cairo University, Egypt
| | - Ahmed Afify
- Cardiology Department, Faculty of Medicine, Cairo University, Egypt
| | - Ahmed Eldamaty
- Cardiology Department, Faculty of Medicine, Cairo University, Egypt
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35
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Büren C, Kamp MA, Munoz-Bendix C, Steiger HJ, Windolf J, Dibué-Adjei M. Can the combination of hyperthermia, seizures and ion channel dysfunction cause fatal post-ictal cerebral edema in patients with SCN1A mutations? EPILEPSY & BEHAVIOR CASE REPORTS 2017; 9:29-32. [PMID: 29692967 PMCID: PMC5913039 DOI: 10.1016/j.ebcr.2017.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 10/31/2022]
Abstract
A 21-year-old male with an SCN1A mutation died of cerebral herniation 3 h after a seizure occurring during physical activity. Cases of fatal cerebral edema in patients with SCN1A mutations after fever and status epilepticus have been recently reported raising the question whether sodium channel dysfunction may contribute to cerebral edema and thereby contribute to the increased premature mortality in Dravet Syndrome. We report on our patient and discuss whether the combination of hyperthermia and ion channel dysfunction may not only trigger seizures but also a fatal pathophysiological cascade of cerebral edema and herniation leading to cardiorespiratory collapse.
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Affiliation(s)
- Carina Büren
- Department for Trauma- and Hand Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany
| | - Marcel Alexander Kamp
- Department for Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany
| | - Christopher Munoz-Bendix
- Department for Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany
| | - Hans-Jakob Steiger
- Department for Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany
| | - Joachim Windolf
- Department for Trauma- and Hand Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany
| | - Maxine Dibué-Adjei
- Department for Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Moorenstraße 5, D-40225 Düsseldorf, Germany.,LivaNova Deutschland GmbH (a LivaNova PLC-owned subsidiary), Lindberghstr 25, D-80939 Munich, Germany
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36
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Musteata M, Mocanu D, Stanciu GD, Armasu M, Solcan G. Interictal cardiac autonomic nervous system disturbances in dogs with idiopathic epilepsy. Vet J 2017; 228:41-45. [PMID: 29153107 DOI: 10.1016/j.tvjl.2017.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
Autonomic nervous system (ANS) activity in the interictal period (InIp) in dogs with presumed idiopathic epilepsy (pIE) was assessed using heart rate variability (HRV) analysis. The HRVs obtained from 28 pIE dogs with interictal epileptic discharges (InIEd; 11 with treatment and 17 without treatment) detected on electroencephalography (EEG) were compared with those obtained from 13 healthy dogs. On electrocardiographic (ECG) study, the P wave dispersion (PWD; P<0.001), P max (P=0.004) and corrected QT interval (QTc; P=0.025) were significantly increased in the pIE group. On the basis of HRV analysis, the pIE dogs had an increased activity of the parasympathetic component of the ANS, including the percentage of R-R interval (pNN50%) that differs more than 50ms (P=0.011) and high frequency band (HF; P=0.041). Administration of phenobarbitone had no influence on the ANS pattern when pIE subgroups were compared (P>0.05). In InIp, dogs elicited specific conductibility delays of the electrical impulses (increased PWD and QTc interval); these delays are considered to be risk factors for developing severe arrhythmias, such as atrial fibrillation and ventricular tachycardia. When compared with human beings, a different ANS pattern characterised by increased parasympathetic activity was observed, which may influence the therapeutic approach of IE in dogs.
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Affiliation(s)
- M Musteata
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine 'Ion Ionescu de la Brad' Iaşi, 8 Mihail Sadoveanu Alley, Iaşi RO-700489, Romania
| | - D Mocanu
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine 'Ion Ionescu de la Brad' Iaşi, 8 Mihail Sadoveanu Alley, Iaşi RO-700489, Romania
| | - G D Stanciu
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine 'Ion Ionescu de la Brad' Iaşi, 8 Mihail Sadoveanu Alley, Iaşi RO-700489, Romania
| | - M Armasu
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine 'Ion Ionescu de la Brad' Iaşi, 8 Mihail Sadoveanu Alley, Iaşi RO-700489, Romania
| | - G Solcan
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine 'Ion Ionescu de la Brad' Iaşi, 8 Mihail Sadoveanu Alley, Iaşi RO-700489, Romania.
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37
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Ali W, Bubolz BA, Nguyen L, Castro D, Coss-Bu J, Quach MM, Kennedy CE, Anderson AE, Lai YC. Epilepsy is associated with ventricular alterations following convulsive status epilepticus in children. Epilepsia Open 2017; 2:432-440. [PMID: 29430560 PMCID: PMC5800777 DOI: 10.1002/epi4.12074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective Convulsive status epilepticus can exert profound cardiovascular effects in adults, including ventricular depolarization–repolarization abnormalities. Whether status epilepticus adversely affects ventricular electrical properties in children is less understood. Therefore, we sought to characterize ventricular alterations and the associated clinical factors in children following convulsive status epilepticus. Methods We conducted a 2‐year retrospective case–control study. Children between 1 month and 21 years of age were included if they were admitted to the pediatric intensive care unit with primary diagnosis of convulsive status epilepticus and had 12‐lead electrocardiogram (ECG) within 24 h of admission. Children with heart disease or ion channelopathy, or who were on vasoactive medications were excluded. Age‐matched control subjects had no history of seizures or epilepsy. The primary outcome was ventricular abnormalities represented by ST segment changes, abnormal T wave, QRS axis deviation, and corrected QT (QTc) interval prolongation. The secondary outcomes included QT/RR relationship, beat‐to‐beat QTc interval variability, ECG interval measurement between groups, and clinical factors associated with ECG abnormalities. Results Of 317 eligible children, 59 met the inclusion criteria. History of epilepsy was present in 31 children (epileptic) and absent in 28 children (nonepileptic). Compared with the control subjects (n = 31), the status epilepticus groups were more likely to have an abnormal ECG, with overall odds ratios of 3.8 and 7.0 for the nonepileptic and the epileptic groups, respectively. Simple linear regression analysis demonstrated that children with epilepsy exhibited impaired dependence and adaptation of the QT interval on heart rate. Beat‐to‐beat QTc interval variability, a marker of ventricular repolarization instability, was increased in children with epilepsy. Significance Convulsive status epilepticus can adversely affect ventricular electrical properties and stability in children, especially those with epilepsy. These findings suggest that children with epilepsy may be particularly vulnerable to seizure‐induced arrhythmias. Therefore, postictal cardiac surveillance may be warranted in this population.
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Affiliation(s)
- Wail Ali
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, West Virginia University, Morgantown, WV
| | - Beth A Bubolz
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Linh Nguyen
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Danny Castro
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jorge Coss-Bu
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Michael M Quach
- Section of Pediatric Neurology and Developmental Neuroscience; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Curtis E Kennedy
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Anne E Anderson
- Section of Pediatric Neurology and Developmental Neuroscience; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Yi-Chen Lai
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
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Sanchez-Larsen A, Aznar-Lain G, Benito B, Principe A, Ley M, Tauste Campo A, Rocamora R. Post-ictal atrial fibrillation detected during video-EEG monitoring: Case report, proposed physiopathologic mechanism and therapeutic considerations. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 8:40-43. [PMID: 28856096 PMCID: PMC5565630 DOI: 10.1016/j.ebcr.2017.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/13/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Alvaro Sanchez-Larsen
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Gemma Aznar-Lain
- Epilepsy Monitoring Unit, Pediatric Department, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader 88, 08003 Barcelona, Spain
| | - Begoña Benito
- Electrophysiology Unit, Department of Cardiology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader 88, 08003 Barcelona, Spain
| | - Alessandro Principe
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader 88, 08003 Barcelona, Spain
| | - Miguel Ley
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Adrià Tauste Campo
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader 88, 08003 Barcelona, Spain
| | - Rodrigo Rocamora
- Epilepsy Monitoring Unit, Department of Neurology, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain.,IMIM (Hospital del Mar Medical Research Institute), Carrer del Dr. Aiguader 88, 08003 Barcelona, Spain
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Lee SM, Byeon HJ, Kim BH, Lee J, Jeong JY, Lee JH, Moon JH, Park C, Choi H, Lee SH, Lee KH. Flexible and implantable capacitive microelectrode for bio-potential acquisition. BIOCHIP JOURNAL 2017. [DOI: 10.1007/s13206-017-1304-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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40
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Baysal-Kirac L, Serbest NG, Şahin E, Dede HÖ, Gürses C, Gökyiğit A, Bebek N, Bilge AK, Baykan B. Analysis of heart rate variability and risk factors for SUDEP in patients with drug-resistant epilepsy. Epilepsy Behav 2017; 71:60-64. [PMID: 28549245 DOI: 10.1016/j.yebeh.2017.04.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/08/2017] [Accepted: 04/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac problems have been suggested as causes of sudden unexpected death in epilepsy (SUDEP). Our aim was to investigate possible associations of cardiac autonomic functions based on heart rate variability (HRV) parameters with risk factors of SUDEP in patients with drug-resistant epilepsy. METHODS Forty-seven patients with drug-resistant seizures and 45 healthy control subjects were enrolled in the study. Interictal time domain parameters of HRV were evaluated with 24-hour Holter recordings. Potential SUDEP risk in patients with epilepsy was estimated using an inventory of seven validated SUDEP risk factors (The SUDEP-7 inventory). RESULTS When compared with the healthy controls, all time domain measures (SDNN-24, SDNN-index, SDANN-index, RMSSD and pNN50) were significantly suppressed in the patient group. Scores of the SUDEP-7 inventory ranged from 1 to 9 with a median 4 out of a maximum possible risk score of 10. Maximum heart rate value in 24-hour Holter recordings and epilepsy duration were correlated with the SUDEP-7 scores (r=0.3, p=0.03). We found no significant association with HRV measures and SUDEP-7 risk factors. One patient diagnosed with Dravet syndrome died of SUDEP, which was autopsy confirmed; his SUDEP-7 inventory score was 7, HRV measures were significantly diminished, and his maximum heart rate (HR) was 208beats/min (maximum HR is between 104 and 188beats/min in normal subjects). CONCLUSION Patients with drug-resistant epilepsy present with significantly lower HRV measures, which may increase the risk for sudden cardiac death. Increased heart rate and diminished HRV measures may constitute one of the possible mechanisms underlying SUDEP and should be diagnosed in patients with epilepsy.
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Affiliation(s)
- Leyla Baysal-Kirac
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nail Güven Serbest
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Erdi Şahin
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Hava Özlem Dede
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Candan Gürses
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ayşen Gökyiğit
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nerses Bebek
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ahmet Kaya Bilge
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
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Banach M, Popławska M, Borowicz-Reutt KK. Sotalol enhances the anticonvulsant action of valproate and diphenylhydantoin in the mouse maximal electroshock model. Pharmacol Rep 2017; 69:1173-1177. [PMID: 29128797 DOI: 10.1016/j.pharep.2017.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/29/2017] [Accepted: 05/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sotalol as a drug blocking β-receptors and potassium KCNH2 channels may interact with different substances that affect seizures. Herein, we present interactions between sotalol and four conventional antiepileptic drugs: carbamazepine, valproate, phenytoin and phenobarbital. METHODS Effects of sotalol and antiepileptics alone on seizures were determined in the electroconvulsive threshold test, while interactions between sotalol and antiepileptic drugs were estimated in the maximal electroshock test in mice. Motor coordination and long-term memory were evaluated, respectively, in the chimney test and passive-avoidance task. Brain concentrations of antiepileptics were determined by fluorescence polarization immunoassay. RESULTS Sotalol at doses up to 100mg/kg did not affect the electroconvulsive threshold. Applied at doses 60-100mg/kg, sotalol potentiated the antielectroshock action of valproate, while at doses 80-100mg/kg that of phenytoin. Sotalol (up to 100mg/kg) did not affect the action of carbamazepine or phenobarbital in the maximal electroshock. Sotalol alone and in combinations with antiepileptics impaired neither motor performance nor long-term memory in mice. Finally, sotalol did not change brain concentration of valproate and phenytoin, so pharmacokinetic interactions between the drugs are not probable. CONCLUSIONS As far as obtained data may be extrapolated into clinical conditions, sotalol may be considered as an arrhythmic drug that does not reduce the action of classical antiepileptic drugs and thereby can be used in epileptic patients with cardiac arrhythmias.
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Affiliation(s)
- Monika Banach
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
| | - Monika Popławska
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Lublin, Poland
| | - Kinga K Borowicz-Reutt
- Independent Unit of Experimental Neuropathophysiology, Department of Pathophysiology, Medical University of Lublin, Lublin, Poland.
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Tahsili-Fahadan P, Geocadin RG. Heart-Brain Axis: Effects of Neurologic Injury on Cardiovascular Function. Circ Res 2017; 120:559-572. [PMID: 28154104 DOI: 10.1161/circresaha.116.308446] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/06/2017] [Accepted: 01/06/2017] [Indexed: 01/23/2023]
Abstract
A complex interaction exists between the nervous and cardiovascular systems. A large network of cortical and subcortical brain regions control cardiovascular function via the sympathetic and parasympathetic outflow. A dysfunction in one system may lead to changes in the function of the other. The effects of cardiovascular disease on the nervous system have been widely studied; however, our understanding of the effects of neurological disorders on the cardiovascular system has only expanded in the past 2 decades. Various pathologies of the nervous system can lead to a wide range of alterations in function and structure of the cardiovascular system ranging from transient and benign electrographic changes to myocardial injury, cardiomyopathy, and even cardiac death. In this article, we first review the anatomy and physiology of the central and autonomic nervous systems in regard to control of the cardiovascular function. The effects of neurological injury on cardiac function and structure will be summarized, and finally, we review neurological disorders commonly associated with cardiovascular manifestations.
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Affiliation(s)
- Pouya Tahsili-Fahadan
- From the Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology & Critical Care Medicine, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- From the Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology & Critical Care Medicine, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Bhandare AM, Kapoor K, Powell KL, Braine E, Casillas-Espinosa P, O'Brien TJ, Farnham MM, Pilowsky PM. Inhibition of microglial activation with minocycline at the intrathecal level attenuates sympathoexcitatory and proarrhythmogenic changes in rats with chronic temporal lobe epilepsy. Neuroscience 2017; 350:23-38. [DOI: 10.1016/j.neuroscience.2017.03.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 12/19/2022]
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Sevcencu C, Nielsen TN, Struijk JJ. Changes in vagus nerve activity associated with ictal tachycardia in pigs. Epilepsy Res 2016; 128:52-60. [PMID: 27810517 DOI: 10.1016/j.eplepsyres.2016.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/24/2016] [Accepted: 10/24/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Ictal tachycardia (IT) is common and may pave the way towards cardiac conditions with high risk potential. However, the mechanisms of IT remain obscure and therefore difficult to control. For example, whereas IT is associated with a sympathetic surge, it is unclear why the IT effects are not opposed by baroreflex cardiac inhibition during seizures. As the vagus nerves (VN) are main mediators for such baroreflexes, this study was performed to investigate the VN activity in IT. METHODS The present experiments were performed in ten pigs where IT seizures were induced by controlled infusion of pentylenetetrazole. The electrocorticogram was recorded using a cranial electrode, the electrocardiogram (ECG) using surface electrodes and the blood pressure (BP) using a catheter inserted in the right carotid artery. The VN activity was recorded from both nerves using cuff electrodes and further analyzed in correlation with the cortical seizures and the associated heart rate (HR), BP and HR variability (HRV) changes. RESULTS The cortical seizures progressed from spike-and-wave (SW) to tonic-clonic (TC) discharges associated with ECG, HR and BP changes proportional with this progression and comparable to the IT effects reported in humans. Those IT effects were accompanied by parasympathetic HRV changes, a 20% VN activation (p=0.004) before the onset of TC seizures, a suppression of this VN activation during the TC episode and a rebound VN activation by 79% (left VN, p=0.02) and 57% (right VN, p=0.03) after the TC offset. Further analysis of an afferent BP-related VN component and a mixed VN component showed normal BP-related afferent input and a suppressed efferent output through both nerves during the TC episode. CONCLUSIONS This study indicates a suppressed ictal VN activation and a rebound postictal VN activation, which may account for the absence of baroreflexes during seizures and the postictal cardiac inhibition, respectively.
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Lhatoo SD, Nei M, Raghavan M, Sperling M, Zonjy B, Lacuey N, Devinsky O. Nonseizure SUDEP: Sudden unexpected death in epilepsy without preceding epileptic seizures. Epilepsia 2016; 57:1161-8. [PMID: 27221596 PMCID: PMC5541994 DOI: 10.1111/epi.13419] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe the phenomenology of monitored sudden unexpected death in epilepsy (SUDEP) occurring in the interictal period where death occurs without a seizure preceding it. METHODS We report a case series of monitored definite and probable SUDEP where no electroclinical evidence of underlying seizures was found preceding death. RESULTS Three patients (two definite and one probable) had SUDEP. They had a typical high SUDEP risk profile with longstanding intractable epilepsy and frequent generalized tonic-clonic seizures (GTCS). All patients had varying patterns of respiratory and bradyarrhythmic cardiac dysfunction with profound electroencephalography (EEG) suppression. In two patients, patterns of cardiorespiratory failure were similar to those seen in some patients in the Mortality in Epilepsy Monitoring Units Study (MORTEMUS). SIGNIFICANCE SUDEP almost always occur postictally, after GTCS and less commonly after a partial seizure. Monitored SUDEP or near-SUDEP cases without a seizure have not yet been reported in literature. When nonmonitored SUDEP occurs in an ambulatory setting without an overt seizure, the absence of EEG information prevents the exclusion of a subtle seizure. These cases confirm the existence of nonseizure SUDEP; such deaths may not be prevented by seizure detection-based devices. SUDEP risk in patients with epilepsy may constitute a spectrum of susceptibility wherein some are relatively immune, death occurs in others with frequent GTCS with one episode of seizure ultimately proving fatal, while in others still, death may occur even in the absence of a seizure. We emphasize the heterogeneity of SUDEP phenomena.
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Affiliation(s)
- Samden D Lhatoo
- Epilepsy Center, UH Case Medical Center, Cleveland, Ohio, U.S.A
- NINDS Center for SUDEP Research (CSR; Center without Walls)
| | - Maromi Nei
- NINDS Center for SUDEP Research (CSR; Center without Walls)
- Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Manoj Raghavan
- Adult Comprehensive Epilepsy Center, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Michael Sperling
- Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Bilal Zonjy
- Epilepsy Center, UH Case Medical Center, Cleveland, Ohio, U.S.A
- NINDS Center for SUDEP Research (CSR; Center without Walls)
| | - Nuria Lacuey
- Epilepsy Center, UH Case Medical Center, Cleveland, Ohio, U.S.A
- NINDS Center for SUDEP Research (CSR; Center without Walls)
| | - Orrin Devinsky
- NINDS Center for SUDEP Research (CSR; Center without Walls)
- NYU Langone Comprehensive Epilepsy Center, New York University Langone Medical Center, New York, New York, U.S.A
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Jaychandran R, Chaitanya G, Satishchandra P, Bharath RD, Thennarasu K, Sinha S. Monitoring peri-ictal changes in heart rate variability, oxygen saturation and blood pressure in epilepsy monitoring unit. Epilepsy Res 2016; 125:10-8. [PMID: 27300719 DOI: 10.1016/j.eplepsyres.2016.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The peri-ictal autonomic disturbances have been studied as predictors of seizure outcome and as markers of seizure onset. We studied the changes in heart rate (HR), HRV, oxygen saturation and blood pressure (BP) in the peri-ictal period in patients with drug-resistant localization-related epilepsy. METHODOLOGY Ninety one subjects undergoing video-EEG monitoring, underwent continuous HR, SpO2, BP and Lead II ECG monitoring. The changes during the preictal, ictal and postictal periods were analyzed for 57 seizures in 42 patients with artifact-free recordings and correlated with VEEG ictal onset and MRI characteristics. RESULTS Ictal tachycardia was noted in 15 (26.3%) seizures, of which, 60% had temporal lobe onset. HR increased by an average of 20.1% from pre-ictal to ictal phases (p=0.04). Ictal bradycardia was noted in one event with right temporal seizure onset. Heart rate variability (HRV) analysis of the preictal, ictal and postictal phases showed an increase in the sympathetic and decrease in parasympathetic activity during the ictus with relatively preserved total power. Ictal oxygen desaturation (84.1%±3.5%) was noticed in 10 (17.5%) seizures. Ictal hypertension was observed in 15 (26.3%); ictal hypotension was noted in 5 (8.7%) seizures. Both the systolic BP and diastolic BPs increased from the pre-ictal to ictal phase (p=0.01). CONCLUSIONS Peri-ictal dysautonomia can present in variable patterns and can be measured and compared over different modalities such as BP, HR and HRV. Though degree of tachycardia and increase in BP were higher during extratemporal onset of seizures, a fall in variability was noted in seizures of temporal lobe origin. Oxygen desaturation is not an uncommon event during the peri-ictal period in localization related epilepsy.
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Affiliation(s)
| | - G Chaitanya
- Departments of Neurology, India; Departments of Clinical Neurosciences, India
| | | | - R D Bharath
- Departments of Neuroimaging and Interventional Radiology (NIIR), India
| | | | - S Sinha
- Departments of Neurology, India.
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Rugg-Gunn F, Duncan J, Hjalgrim H, Seyal M, Bateman L. From unwitnessed fatality to witnessed rescue: Nonpharmacologic interventions in sudden unexpected death in epilepsy. Epilepsia 2016; 57 Suppl 1:26-34. [PMID: 26749014 DOI: 10.1111/epi.13231] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 12/18/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) risk reduction remains a critical aim in epilepsy care. To date, only aggressive medical and surgical efforts to control seizures have been demonstrated to be of benefit. Incomplete understanding of SUDEP mechanisms limits the development of more specific interventions. Periictal cardiorespiratory dysfunction is implicated in SUDEP; postictal electroencephalography (EEG) suppression, coma, and immobility may also play a role. Nocturnal supervision is protective against SUDEP, presumably by permitting intervention in the case of a life-threatening event. Resuscitative efforts were implemented promptly in near-SUDEP cases but delayed in SUDEP deaths in the Mortality in Epilepsy Monitoring Unit Study (MORTEMUS) study. Nursing interventions--including repositioning, oral suctioning, and oxygen administration--reduce seizure duration, respiratory dysfunction, and EEG suppression in the epilepsy monitoring unit (EMU), but have not been studied in outpatients. Cardiac pacemakers or cardioverter-defibrillator devices may be of benefit in a few select individuals. A role for implantable neurostimulators has not yet been established. Seizure detection devices, including those that monitor generalized tonic-clonic seizure-associated movements or cardiorespiratory parameters, may provide a means to permit timely periictal intervention. However, these and other devices, such as antisuffocation pillows, have not been adequately investigated with respect to SUDEP prevention.
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Affiliation(s)
- Fergus Rugg-Gunn
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom.,Chalfont Centre for Epilepsy, Chalfont St. Peter, United Kingdom
| | - John Duncan
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | | | - Masud Seyal
- Department of Neurology, University of California Davis, Sacramento, California, U.S.A
| | - Lisa Bateman
- Department of Neurology, Columbia University, New York, New York, U.S.A
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Tomson T, Surges R, Delamont R, Haywood S, Hesdorffer DC. Who to target in sudden unexpected death in epilepsy prevention and how? Risk factors, biomarkers, and intervention study designs. Epilepsia 2016; 57 Suppl 1:4-16. [PMID: 26749012 DOI: 10.1111/epi.13234] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
The risk of dying suddenly and unexpectedly is increased 24- to 28-fold among young people with epilepsy compared to the general population, but the incidence of sudden unexpected death in epilepsy (SUDEP) varies markedly depending on the epilepsy population. This article first reviews risk factors and biomarkers for SUDEP with the overall aim of enabling identification of epilepsy populations with different risk levels as a background for a discussion of possible intervention strategies. The by far most important clinical risk factor is frequency of generalized tonic-clonic seizures (GTCS), but nocturnal seizures, early age at onset, and long duration of epilepsy have been identified as additional risk factors. Lack of antiepileptic drug (AED) treatment or, in the context of clinical trials, adjunctive placebo versus active treatment is associated with increased risks. Despite considerable research, reliable electrophysiologic (electrocardiography [ECG] or electroencephalography [EEG]) biomarkers of SUDEP risk remain to be established. This is an important limitation for prevention strategies and intervention studies. There is a lack of biomarkers for SUDEP, and until validated biomarkers are found, the endpoint of interventions to prevent SUDEP must be SUDEP itself. These interventions, be they pharmacologic, seizure-detection devices, or nocturnal supervision, require large numbers. Possible methods for assessing prevention measures include public health community interventions, self-management, and more traditional (and much more expensive) randomized clinical trials.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Robert Delamont
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Dale C Hesdorffer
- GH Sergievsky Center and Department of Epidemiology, Columbia University, New York, New York, U.S.A
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Stefanidou M, Carlson C, Friedman D. The relationship between seizure onset zone and ictal tachycardia: An intracranial EEG study. Clin Neurophysiol 2015; 126:2255-60. [DOI: 10.1016/j.clinph.2015.01.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 12/31/2014] [Accepted: 01/21/2015] [Indexed: 11/26/2022]
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Abstract
Sudden unexpected death in epilepsy is likely caused by a cascade of events affecting the vegetative nervous system leading to cardiorespiratory failure and death. Multiple genetic, electrophysiological, neurochemical, and pharmacological cardiac alterations have been associated with epilepsy, which can affect autonomic regulation of the heart and predispose patients to sudden unexpected death in epilepsy. These cardiac and autonomic changes are more frequently seen in patients with longstanding and medication refractory epilepsy and may be a prerequisite for sudden unexpected death in epilepsy. Cardiac changes are also observed within the immediate periictal period in patients with and without preexisting cardiac pathology and could be the tipping point in the cascade of events compromising autonomic, respiratory, and cardiac function during an epileptic convulsion. Better understanding if and how these cardiac alterations can make a particular individual with epilepsy more susceptible to sudden unexpected death in epilepsy will hopefully lead us to more effective preventative strategies.
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