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Direk MÇ, Epcacan S, Özdemir AA, Uysal F, Okuyaz Ç. Effects of levetiracetam treatment on autonomic nervous system functions in pediatric epilepsy patients. Pediatr Int 2023; 65:e15636. [PMID: 37795856 DOI: 10.1111/ped.15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study investigated the effects of levetiracetam (LEV) treatment on cardiac rhythm and heart rate variability. METHODS The study included two groups of patients diagnosed with non-lesional epilepsy who had not yet been treated and who presented to the outpatient pediatric neurology clinic at Van Training and Research Hospital, Van, Turkey, between 2019 and 2020. The heart rate variability (HRV) of 47 patients in the first group, before and at the 3rd month of treatment, and intravenous (IV) LEV loading in 13 patients in the second group was evaluated by Holter electrocardiography (ECG). RESULTS It was determined that the values of triangular index, standard deviation of the RR intervals over a 24-hour period (SDNN), standard deviation of all 5-minute mean RR intervals (SDANN), mean of standard deviations of all normal RR intervals (SDNNI), the percentage of RR intervals with >50-millisecond variation (PNN50), and the square root of mean squared differences of successive RR intervals (RMSSD). HRV of 47 patients under LEV treatment significantly increased in the 3rd month of treatment compared to baseline (p < 0.05). No difference was found in HRV between the intravenous loading and the control group (p > 0.05). CONCLUSIONS Our study suggests that the sympathovagal balance before treatment in the patient group is in favor of the sympathetic nervous system and that the sympathovagal imbalance improves after treatment. Our results show that LEV monotherapy and loading have no negative effect on HRV and potential cardiac arrhythmia risk in children with epilepsy.
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Affiliation(s)
| | - Serdar Epcacan
- Department of Pediatric Cardiology, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Asena Ayca Özdemir
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Fahrettin Uysal
- Department of Turkey Pediatric Cardiology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Çetin Okuyaz
- Department of Pediatric Neurology, Faculty of Medicine, Mersin University, Mersin, Turkey
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2
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Goswami I, Maguire B, Chau V, Tam EW, Pinchefsky E, Whitney R, Wilson D, Miller SP, Cortez MA. Early transient dysautonomia predicts the risk of infantile epileptic spasm syndrome onset: A prospective cohort study. Front Neurol 2022; 13:1090155. [PMID: 36619920 PMCID: PMC9815183 DOI: 10.3389/fneur.2022.1090155] [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: 11/05/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
Background Infantile epileptic spasm syndrome (IESS) is an age-dependent epileptic encephalopathy with a significant risk of developmental regression. This study investigates the association between heart rate variability (HRV) in infants at risk of IESS and the clinical onset of IESS. Methods Sixty neonates at risk of IESS were prospectively followed from birth to 12 months with simultaneous electroencephalogram (EEG) and electrocardiogram recordings for 60 min at every 2-month interval. HRV metrics were calculated from 5 min time-epoch during sleep including frequency domain measures, Poincare analysis including cardiac vagal index (CVI) and cardiac sympathetic index (CSI), and detrended fluctuation analysis (DFA α1, DFA α2). To assess the effect of each HRV metric at the 2-month baseline on the time until the first occurrence of either hypsarrhythmia on EEG and/or clinical spasm, univariate cox-proportional hazard models were fitted for each HRV metric. Results Infantile epileptic spasm syndrome was diagnosed in 20/60 (33%) of the cohort in a 12-month follow-up and 3 (5%) were lost to follow-up. The median age of developing hypsarrhythmia was 25 (7-53) weeks and clinical spasms at 24 (8-40) weeks. Three (5%) patients had clinical spasms without hypsarrhythmia, and 5 (8%) patients had hypsarrhythmia before clinical spasms at the initial presentation. The infants with high CSI (hazard ratio 2.5, 95% CI 1.2-5.2, P = 0.01) and high DFA α1 (hazard ratio 16, 95% CI 1.1-240, P = 0.04) at 2 months were more likely to develop hypsarrhythmia by the first year of age. There was a trend toward decreasing CSI and DFA α1 and increasing CVI in the first 8 months of age. Conclusion Our data suggest that relative sympathetic predominance at an early age of 2 months may be a potential predictor for developing IESS. Hence, early HRV patterns may provide valuable prognostic information in children at risk of IESS allowing early detection and optimization of cognitive outcomes. Whether early intervention to restore sympathovagal balance per se would provide clinical benefit must be addressed by future studies.
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Affiliation(s)
- Ipsita Goswami
- Department of Pediatrics, Divisions of Neonatology, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada,*Correspondence: Ipsita Goswami ✉
| | - Bryan Maguire
- Child Health Evaluative Sciences Research Program, Toronto and Cancer Care Ontario, The Hospital for Sick Children, SickKids Research Institute, Toronto, ON, Canada
| | - Vann Chau
- Department of Pediatrics, Divisions of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily W. Tam
- Department of Pediatrics, Divisions of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elana Pinchefsky
- Department of Pediatrics, Division of Neurology, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Robyn Whitney
- Department of Pediatrics, Divisions of Neurology, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Diane Wilson
- Department of Pediatrics, Divisions of Neonatology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steven P. Miller
- Department of Pediatrics, Divisions of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Miguel A. Cortez
- Department of Pediatrics, Divisions of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Miguel A. Cortez ✉
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3
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Halimeh M, Yang Y, Sheehan T, Vieluf S, Jackson M, Loddenkemper T, Meisel C. Wearable device assessments of antiseizure medication effects on diurnal patterns of electrodermal activity, heart rate, and heart rate variability. Epilepsy Behav 2022; 129:108635. [PMID: 35278938 DOI: 10.1016/j.yebeh.2022.108635] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/04/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
Abstract
Patient-generated health data provide a great opportunity for more detailed ambulatory monitoring and more personalized treatments in many diseases. In epilepsy, robust diagnostics applicable to the ambulatory setting are needed as diagnosis and treatment decisions in current clinical practice are primarily reliant on patient self-reports, which are often inaccurate. Recent work using wearable devices has focused on methods to detect and forecast epileptic seizures. Whether wearable device signals may also contain information about the effect of antiseizure medications (ASMs), which may ultimately help to better monitor their efficacy, has not been evaluated yet. Here we systematically investigated the effect of ASMs on different data modalities (electrodermal activity, EDA, heart rate, HR, and heart rate variability, HRV) simultaneously recorded by a wearable device in 48 patients with epilepsy over several days in the epilepsy long-term monitoring unit at a tertiary hospital. All signals exhibited characteristic diurnal variations. HRV, but not HR or EDA-based metrics, were reduced by ASMs. By assessing multiple signals related to the autonomic nervous system simultaneously, our results provide novel insights into the effects of ASMs on the sympathetic and parasympathetic interplay in the setting of epilepsy and indicate the potential of easy-to-wear wearable devices for monitoring ASM action. Future work using longer data may investigate these metrics on multidien cycles and their utility for detecting seizures, assessing seizure risk, or informing treatment interventions.
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Affiliation(s)
- Mustafa Halimeh
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany
| | - Yonghua Yang
- Hospital of Xi'an Jiaotong University, Pediatric Department, Shaanxi, China
| | | | | | | | | | - Christian Meisel
- Computational Neurology, Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany.
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4
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Myers KA, Sivathamboo S, Perucca P. Heart rate variability measurement in epilepsy: How can we move from research to clinical practice? Epilepsia 2018; 59:2169-2178. [PMID: 30345509 DOI: 10.1111/epi.14587] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/07/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
Our objective was to critically evaluate the literature surrounding heart rate variability (HRV) in people with epilepsy and to make recommendations as to how future research could be directed to facilitate and accelerate integration into clinical practice. We reviewed relevant HRV publications including those involving human subjects with seizures. HRV has been studied in patients with epilepsy for more than 30 years and, overall, patients with epilepsy display altered interictal HRV, suggesting a shift in autonomic balance toward sympathetic dominance. This derangement appears more severe in those with temporal lobe epilepsy and drug-resistant epilepsy. Normal diurnal variation in HRV is also disturbed in at least some people with epilepsy, but this aspect has received less study. Some therapeutic interventions, including vagus nerve stimulation and antiepileptic medications, may partially normalize altered HRV, but studies in this area are sometimes contradictory. During seizures, the changes in HRV may be complex, but the general trend is toward a further increase in sympathetic overactivity. Research in HRV in people with epilepsy has been limited by inconsistent experimental protocols and studies that are often underpowered. HRV measurement has the potential to aid clinical epilepsy management in several possible ways. HRV may be useful in predicting which patients are likely to benefit from surgical interventions such as vagus nerve stimulation and focal cerebral resection. As well, HRV could eventually have utility as a biomarker of risk for sudden unexpected death in epilepsy (SUDEP). However, at present, the inconsistent measurement protocols used in research are hindering translation into clinical practice. A minimum protocol for HRV evaluation, to be used in all studies involving epilepsy patients, is necessary to eventually allow HRV to become a useful tool for clinicians. We propose a straightforward protocol, involving 5-minute measurements of root mean square of successive differences in wakefulness and light sleep.
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Affiliation(s)
- Kenneth A Myers
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Child Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Shobi Sivathamboo
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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5
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He L, Wang J, Liu Y, Dong W, Yang H, Luo Y, Xiang T, Luo L. Percutaneous mastoid electrical stimulator alleviates autonomic dysfunction in patients with acute ischemic stroke. Neurol Res 2018; 40:995-1000. [PMID: 30111262 DOI: 10.1080/01616412.2018.1508548] [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: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Poststroke prognosis is associated with autonomic status. The purpose of our study was to determine whether percutaneous mastoid electrical stimulator (PMES) can alleviate abnormal heart rate variability (HRV) and improve clinical outcome. METHODS This prospective, randomized, double-blinded, placebo-controlled study enrolled a total of 140 patients with autonomic dysfunction within 3d after acute ischemic stroke. The patients were treated with PMES or sham stimulation once daily over a period of 2 weeks. HRV was primarily assessed by the fractal dimension (FD) at admission and 2 weeks. All patients were followed up for 3 months. The clinical outcome was death and major disability (modified Rankin Scale score≥ 3) at 3 months after acute ischemic stroke. RESULTS FD of the 2-week treatment period increased in PMES groups. PMES can significantly alleviate abnormal HRV. The difference in FD of the 2-week treatment period between the PMES and sham groups was significant (1.14 ± 0.27 vs. 1.00 ± 0.23; P = 0.001). In fully adjusted models, PMES was associated with reduced 3-month mortality (adjusted odds ratio, 0.32; 95% confidence interval, 0.11-0.93; P = 0.036). No significant group differences were seen in three major disability and composite outcome (P > 0.05). CONCLUSIONS PMES was a safe, effective, and low-cost therapy to alleviate HRV and could significantly reduce mortality in the early recovery phase after acute ischemic stroke.
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Affiliation(s)
- Lanying He
- a Department of Neurology , The Second People's Hospital of Chengdu , Chengdu , P. R. China
| | - Jian Wang
- a Department of Neurology , The Second People's Hospital of Chengdu , Chengdu , P. R. China
| | - Ya Liu
- b Department of Geriatrics , The Second People's Hospital of Chengdu , Chengdu , P. R. China
| | - Weiwei Dong
- c Department of Neurology , The Second Affiliated Hospital, Chongqing Medical University , Chongqing , P. R. China
| | - Hao Yang
- d College of Electrical Engineering, Institute of Electrical Technology , Chongqing University , Chongqing , P. R. China
| | - Yong Luo
- c Department of Neurology , The Second Affiliated Hospital, Chongqing Medical University , Chongqing , P. R. China
| | - Tao Xiang
- e Rehabilitation department , The Second People's Hospital of Chengdu , Chengdu , P. R. China
| | - Lun Luo
- e Rehabilitation department , The Second People's Hospital of Chengdu , Chengdu , P. R. China
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Myers KA, Bello-Espinosa LE, Symonds JD, Zuberi SM, Clegg R, Sadleir LG, Buchhalter J, Scheffer IE. Heart rate variability in epilepsy: A potential biomarker of sudden unexpected death in epilepsy risk. Epilepsia 2018; 59:1372-1380. [PMID: 29873813 DOI: 10.1111/epi.14438] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is a tragic and devastating event for which the underlying pathophysiology remains poorly understood; this study investigated whether abnormalities in heart rate variability (HRV) are linked to SUDEP in patients with epilepsy due to mutations in sodium channel (SCN) genes. METHODS We retrospectively evaluated HRV in epilepsy patients using electroencephalographic studies to study the potential contribution of autonomic dysregulation to SUDEP risk. We extracted HRV data, in wakefulness and sleep, from 80 patients with drug-resistant epilepsy, including 40 patients with mutations in SCN genes and 40 control patients with non-SCN drug-resistant epilepsy. From the SCN group, 10 patients had died of SUDEP. We compared HRV between SUDEP and non-SUDEP groups, specifically studying awake HRV and sleep:awake HRV ratios. RESULTS The SUDEP patients had the most severe autonomic dysregulation, showing lower awake HRV and either extremely high or extremely low ratios of sleep-to-awake HRV in a subgroup analysis. A secondary analysis comparing the SCN and non-SCN groups indicated that autonomic dysfunction was slightly worse in the SCN epilepsy group. SIGNIFICANCE These findings suggest that autonomic dysfunction is associated with SUDEP risk in patients with epilepsy due to sodium channel mutations. The relationship of HRV to SUDEP merits further study; HRV may eventually have potential as a biomarker of SUDEP risk, which would allow for more informed counseling of patients and families, and also serve as a useful outcome measure for research aimed at developing therapies and interventions to reduce SUDEP risk.
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Affiliation(s)
- Kenneth A Myers
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Child Neurology, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Luis E Bello-Espinosa
- Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph D Symonds
- College of Medicine, Veterinary, and Life Sciences, School of Medicine, University of Glasgow, Glasgow, UK.,Paediatric Neurosciences Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | - Sameer M Zuberi
- College of Medicine, Veterinary, and Life Sciences, School of Medicine, University of Glasgow, Glasgow, UK.,Paediatric Neurosciences Research Group, Royal Hospital for Sick Children, Glasgow, UK
| | - Robin Clegg
- Department of Pediatrics, Section of Cardiology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lynette G Sadleir
- Department of Paediatrics and Child Health, University of Otago Wellington, Wellington, New Zealand
| | - Jeffrey Buchhalter
- Department of Pediatrics, Section of Neurology, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ingrid E Scheffer
- Department of Medicine, Epilepsy Research Centre, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Flemington, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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