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Gould L, Reid CA, Rodriguez AJ, Devinsky O. Video Analyses of Sudden Unexplained Deaths in Toddlers. Neurology 2024; 102:e208038. [PMID: 38175965 PMCID: PMC11097764 DOI: 10.1212/wnl.0000000000208038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES More than 2,900 US children aged younger than 4 years die from unknown causes each year, accounting for more than 219,000 life years lost annually. They are mostly sleep-related and unwitnessed with unremarkable autopsies, limiting our understanding of death mechanisms. We sought to understand potential mechanisms of death by evaluating videos of sudden deaths in toddlers. METHODS In our registry of 301 sudden unexplained child deaths, a series of 7 consecutively enrolled cases with home video recordings of the child's last sleep period were independently assessed by 8 physicians for video quality, movement, and sound. RESULTS Four boys and 3 girls (13-27 months at death) with terminal videos shared similar demographic features to the 293 other registry cases without video recordings. Five video recordings were continuous and 2 were triggered by sound or motion. Two lacked audio. All continuous recordings included a terminal convulsive event lasting 8-50 seconds; 4 children survived for >2.5 minutes postconvulsion. Among discontinuous videos, time lapses limited review; 1 suggested a convulsive event. Six were prone with face down, and 1 had autopsy evidence of airway obstruction. Primary cardiac arrhythmias were not supported; all 7 children had normal cardiac pathology and whole-exome sequencing identified no known cardiac disease variants. DISCUSSION Audio-visual recordings in 7 toddlers with unexplained sudden deaths strongly implicate that deaths were related to convulsive seizures, suggesting that many unexplained sleep-related deaths may result from seizures.
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Affiliation(s)
- Laura Gould
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Codi-Ann Reid
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Alcibiades J Rodriguez
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
| | - Orrin Devinsky
- From the NYU Grossman School of Medicine (L.G., C.-A.R., A.J.R., O.D.), and NYU Comprehensive Epilepsy Center (L.G., C.-A.R., A.J.R., O.D.), New York
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Luijerink L, Rodriguez M, Machaalani R. Quantifying GFAP immunohistochemistry in the brain - Introduction of the Reactivity score (R-score) and how it compares to other methodologies. J Neurosci Methods 2024; 402:110025. [PMID: 38036185 DOI: 10.1016/j.jneumeth.2023.110025] [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: 07/05/2023] [Revised: 10/08/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Immunohistochemical upregulation of glial fibrillary acidic protein (GFAP) is commonly used to detect astrogliosis in tissue sections and includes measurement of intensity and/or distribution of staining. There remains a lack of standard objective measures when diagnosing astrogliosis and its severity. NEW METHOD Aim was to test a novel semi-quantitative assessment of GFAP which we term reactivity (R)-score, on its reproducibility and sensitivity to measure astrogliosis. The R-score, which is based on the proportion of astrocytes seen at each level of reactivity, was compared to 3 other commonly employed quantification methods in research: (1) thresholding, (2) point-counting, and (3) qualitative grading. Sub-regions of the hippocampus, medulla, and cerebellum were studied in piglet, and 4 human cases with clinically reported astrogliosis. Intra-assay coefficient of variation (CV) and percentage agreement cut-offs of ≤ 20% and ≥ 75% were used respectively to compare amongst the methods, with outcome measures being reproducibility across serial and non-serial sections, resilience to changes in experimental conditions, and inter- and intra-rater concordance. RESULTS Averaged across 3 brain regions, the intra-assay coefficient of variation (CV) was 5% for R-score, with inter and intra-rater kappa scores being 0.99 and 0.95 respectively. COMPARISON WITH EXISTING METHODS AND CONCLUSIONS Based on CV values, the R-score was superior to thresholding (CV of 51%) and point-counting (CV of 16%), with the qualitative grade being found to be on par (percentage agreement 95%). Given the ease, reproducibility and selectivity of the R-score, we propose its validity in future research purposes and clinical application.
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Affiliation(s)
- Lauren Luijerink
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Rita Machaalani
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
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Leitner DF, William C, Faustin A, Askenazi M, Kanshin E, Snuderl M, McGuone D, Wisniewski T, Ueberheide B, Gould L, Devinsky O. Proteomic differences in hippocampus and cortex of sudden unexplained death in childhood. Acta Neuropathol 2022; 143:585-599. [PMID: 35333953 PMCID: PMC8953962 DOI: 10.1007/s00401-022-02414-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 11/01/2022]
Abstract
Sudden unexplained death in childhood (SUDC) is death of a child over 1 year of age that is unexplained after review of clinical history, circumstances of death, and complete autopsy with ancillary testing. Multiple etiologies may cause SUDC. SUDC and sudden unexpected death in epilepsy (SUDEP) share clinical and pathological features, suggesting some similarities in mechanism of death and possible abnormalities in hippocampus and cortex. To identify molecular signaling pathways, we performed label-free quantitative mass spectrometry on microdissected frontal cortex, hippocampal dentate gyrus (DG), and cornu ammonis (CA1-3) in SUDC (n = 19) and pediatric control cases (n = 19) with an explained cause of death. At a 5% false discovery rate (FDR), we found differential expression of 660 proteins in frontal cortex, 170 in DG, and 57 in CA1-3. Pathway analysis of altered proteins identified top signaling pathways associated with activated oxidative phosphorylation (p = 6.3 × 10-15, z = 4.08) and inhibited EIF2 signaling (p = 2.0 × 10-21, z = - 2.56) in frontal cortex, and activated acute phase response in DG (p = 8.5 × 10-6, z = 2.65) and CA1-3 (p = 4.7 × 10-6, z = 2.00). Weighted gene correlation network analysis (WGCNA) of clinical history indicated that SUDC-positive post-mortem virology (n = 4/17) had the most significant module in each brain region, with the top most significant associated with decreased mRNA metabolic processes (p = 2.8 × 10-5) in frontal cortex. Additional modules were associated with clinical history, including fever within 24 h of death (top: increased mitochondrial fission in DG, p = 1.8 × 10-3) and febrile seizure history (top: decreased small molecule metabolic processes in frontal cortex, p = 8.8 × 10-5) in all brain regions, neuropathological hippocampal findings in the DG (top: decreased focal adhesion, p = 1.9 × 10-3). Overall, cortical and hippocampal protein changes were present in SUDC cases and some correlated with clinical features. Our studies support that proteomic studies of SUDC cohorts can advance our understanding of the pathogenesis of these tragedies and may inform the development of preventive strategies.
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Haynes RL, Kinney HC, Haas EA, Duncan JR, Riehs M, Trachtenberg F, Armstrong DD, Alexandrescu S, Cryan JB, Hefti MM, Krous HF, Goldstein RD, Sleeper LA. Medullary Serotonergic Binding Deficits and Hippocampal Abnormalities in Sudden Infant Death Syndrome: One or Two Entities? Front Pediatr 2021; 9:762017. [PMID: 34993162 PMCID: PMC8724302 DOI: 10.3389/fped.2021.762017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/17/2021] [Indexed: 11/27/2022] Open
Abstract
Sudden infant death syndrome (SIDS) is understood as a syndrome that presents with the common phenotype of sudden death but involves heterogenous biological causes. Many pathological findings have been consistently reported in SIDS, notably in areas of the brain known to play a role in autonomic control and arousal. Our laboratory has reported abnormalities in SIDS cases in medullary serotonin (5-HT) receptor 1A and within the dentate gyrus of the hippocampus. Unknown, however, is whether the medullary and hippocampal abnormalities coexist in the same SIDS cases, supporting a biological relationship of one abnormality with the other. In this study, we begin with an analysis of medullary 5-HT1A binding, as determined by receptor ligand autoradiography, in a combined cohort of published and unpublished SIDS (n = 86) and control (n = 22) cases. We report 5-HT1A binding abnormalities consistent with previously reported data, including lower age-adjusted mean binding in SIDS and age vs. diagnosis interactions. Utilizing this combined cohort of cases, we identified 41 SIDS cases with overlapping medullary 5-HT1A binding data and hippocampal assessment and statistically addressed the relationship between abnormalities at each site. Within this SIDS analytic cohort, we defined abnormal (low) medullary 5-HT1A binding as within the lowest quartile of binding adjusted for age and we examined three specific hippocampal findings previously identified as significantly more prevalent in SIDS compared to controls (granular cell bilamination, clusters of immature cells in the subgranular layer, and single ectopic cells in the molecular layer of the dentate gyrus). Our data did not find a strong statistical relationship between low medullary 5-HT1A binding and the presence of any of the hippocampal abnormalities examined. It did, however, identify a subset of SIDS (~25%) with both low medullary 5-HT1A binding and hippocampal abnormalities. The subset of SIDS cases with both low medullary 5-HT1A binding and single ectopic cells in the molecular layer was associated with prenatal smoking (p = 0.02), suggesting a role for the exposure in development of the two abnormalities. Overall, our data present novel information on the relationship between neuropathogical abnormalities in SIDS and support the heterogenous nature and overall complexity of SIDS pathogenesis.
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Affiliation(s)
- Robin L. Haynes
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Hannah C. Kinney
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Elisabeth A. Haas
- Department of Research, Rady's Children's Hospital, San Diego, CA, United States
| | | | - Molly Riehs
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | | | - Dawna D. Armstrong
- Department of Pathology (Emeritus), Baylor College of Medicine, Houston, TX, United States
| | - Sanda Alexandrescu
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jane B. Cryan
- Department of Neuropathology, Children's Health Ireland and Beaumont Hospitals, Dublin, Ireland
| | - Marco M. Hefti
- Department of Pathology, University of Iowa, Iowa City, IA, United States
| | - Henry F. Krous
- Department of Pathology (Emeritus), Rady Children's Hospital, San Diego, CA, United States
- Department of Pediatrics (Emeritus), University of California, San Diego, San Diego, CA, United States
| | - Richard D. Goldstein
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Robert's Program on Sudden Unexpected Death in Pediatrics, Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
| | - Lynn A. Sleeper
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
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Leitner DF, Faustin A, Verducci C, Friedman D, William C, Devore S, Wisniewski T, Devinsky O. Neuropathology in the North American sudden unexpected death in epilepsy registry. Brain Commun 2021; 3:fcab192. [PMID: 34514397 PMCID: PMC8417454 DOI: 10.1093/braincomms/fcab192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/12/2022] Open
Abstract
Sudden unexpected death in epilepsy is the leading category of epilepsy-related death and the underlying mechanisms are incompletely understood. Risk factors can include a recent history and high frequency of generalized tonic-clonic seizures, which can depress brain activity postictally, impairing respiration, arousal and protective reflexes. Neuropathological findings in sudden unexpected death in epilepsy cases parallel those in other epilepsy patients, with no implication of novel structures or mechanisms in seizure-related deaths. Few large studies have comprehensively reviewed whole brain examination of such patients. We evaluated 92 North American Sudden unexpected death in epilepsy Registry cases with whole brain neuropathological examination by board-certified neuropathologists blinded to the adjudicated cause of death, with an average of 16 brain regions examined per case. The 92 cases included 61 sudden unexpected death in epilepsy (40 definite, 9 definite plus, 6 probable, 6 possible) and 31 people with epilepsy controls who died from other causes. The mean age at death was 34.4 years and 65.2% (60/92) were male. The average age of death was younger for sudden unexpected death in epilepsy cases than for epilepsy controls (30.0 versus 39.6 years; P = 0.006), and there was no difference in sex distribution respectively (67.3% male versus 64.5%, P = 0.8). Among sudden unexpected death in epilepsy cases, earlier age of epilepsy onset positively correlated with a younger age at death (P = 0.0005) and negatively correlated with epilepsy duration (P = 0.001). Neuropathological findings were identified in 83.7% of the cases in our cohort. The most common findings were dentate gyrus dysgenesis (sudden unexpected death in epilepsy 50.9%, epilepsy controls 54.8%) and focal cortical dysplasia (FCD) (sudden unexpected death in epilepsy 41.8%, epilepsy controls 29.0%). The neuropathological findings in sudden unexpected death in epilepsy paralleled those in epilepsy controls, including the frequency of total neuropathological findings as well as the specific findings in the dentate gyrus, findings pertaining to neurodevelopment (e.g. FCD, heterotopias) and findings in the brainstem (e.g. medullary arcuate or olivary dysgenesis). Thus, like prior studies, we found no neuropathological findings that were more common in sudden unexpected death in epilepsy cases. Future neuropathological studies evaluating larger sudden unexpected death in epilepsy and control cohorts would benefit from inclusion of different epilepsy syndromes with detailed phenotypic information, consensus among pathologists particularly for more subjective findings where observations can be inconsistent, and molecular approaches to identify markers of sudden unexpected death in epilepsy risk or pathogenesis.
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Affiliation(s)
- Dominique F Leitner
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Arline Faustin
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Chloe Verducci
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Daniel Friedman
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Christopher William
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Sasha Devore
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Thomas Wisniewski
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Center for Cognitive Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Pathology, NYU Langone Health and School of Medicine, New York, NY, USA
- Department of Psychiatry, NYU Langone Health and School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, NYU Grossman School of Medicine, New York, NY, USA
- Department of Neurology, NYU Langone Health and School of Medicine, New York, NY, USA
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