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Rajaleelan W, Chowdhury T, Moga R, Todaro C, Zadeh G, Wang J, Singh M. Perioperative Considerations in a Patient with Kleine–Levin Syndrome Undergoing a Neurosurgical Procedure under General Anesthesia. Asian J Neurosurg 2022; 17:480-484. [PMID: 36398179 PMCID: PMC9665980 DOI: 10.1055/s-0042-1756624] [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: 11/06/2022] Open
Abstract
Kleine–Levin syndrome (KLS) is a rare central disorder of daytime hypersomnolence and is often characterized by a relapsing and remitting course, recurrent episodes of excessive sleep lasting from 12 to 20 hours a day, and symptoms including hyperphagia, hallucinations, derealization, disorientation, and hypersexuality. There are numerous perioperative considerations in dealing with KLS that include challenges during induction of anesthesia, delayed emergence, postoperative sleep disorders, and delirium. However, due to its rare occurrence, the anesthetic considerations of KLS remain poorly described. This case report outlines the anesthetic considerations and management of a young female patient with KLS who underwent transnasal excision of a trigeminal schwannoma under general anesthesia.
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Affiliation(s)
- Wesley Rajaleelan
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
| | - Tumul Chowdhury
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
| | - Rebecca Moga
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
| | - Carla Todaro
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Justin Wang
- Department of Neurosurgery, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
- Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada
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Xiang X, Chen Y, Li KX, Fang J, Bickler PE, Guan Z, Zhou W. Neuroanatomical Basis for the Orexinergic Modulation of Anesthesia Arousal and Pain Control. Front Cell Neurosci 2022; 16:891631. [PMID: 35558876 PMCID: PMC9090436 DOI: 10.3389/fncel.2022.891631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Hypothalamic orexin (hypocretin) neurons play crucial roles in arousal control. Their involvement in anesthesia and analgesia remains to be better understood. In order to enhance our view on the neuroanatomy, we systematically mapped the projections of orexin neurons with confocal microscope and light sheet microscope. We specifically expressed optogenetic opsins tagged with fluorescence markers in orexin neurons through adeno-associated viral infection in the mouse brain. The imaging results revealed fine details and novel features of the orexin projections throughout the brain, particularly related to the nuclei regulating arousal and pain. We then optogenetically activated orexin neurons in the lateral hypothalamus to study the effects on anesthesia-related behaviors. cFos staining showed that optogenetic stimulation can activate orexin neurons in the ChR2-mCherry group, but not the control mCherry group (62.86 ± 3.923% vs. 7.9 ± 2.072%; P < 0.0001). In behavior assays, optogenetic stimulation in the ChR2-mCherry group consistently elicited robust arousal from light isoflurane anesthesia (9.429 ± 3.804 s vs. 238.2 ± 17.42 s; P < 0.0001), shortened the emergence time after deep isoflurane anesthesia (109.5 ± 13.59 s vs. 213.8 ± 21.77 s; P = 0.0023), and increased the paw withdrawal latency in a hotplate test (11.45 ± 1.185 s vs. 8.767 ± 0.7775; P = 0.0317). The structural details of orexin fibers established the neuroanatomic basis for studying the role of orexin in anesthesia and analgesia.
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Affiliation(s)
- Xuaner Xiang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Yuzhang Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Ke-Xin Li
- Department of Physiology, University of California, San Francisco, San Francisco, CA, United States
| | - Jianqiao Fang
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Philip E. Bickler
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Wei Zhou
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Wei Zhou,
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Spruyt K. Narcolepsy Presentation in Diverse Populations: an Update. CURRENT SLEEP MEDICINE REPORTS 2020; 6:239-250. [PMID: 33251089 PMCID: PMC7686447 DOI: 10.1007/s40675-020-00195-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 11/05/2022]
Abstract
Purpose of Review We performed a literature search to generate incidence and prevalence rates of narcolepsy in diverse populations based on current available data. Recent Findings With an onset in childhood, narcolepsy often has a delayed diagnosis due to symptoms of excessive daytime sleepiness not being recognized or being misdiagnosed. Clinical, electrophysiological, and biological tests are needed in order to diagnose narcolepsy. At the same time, the discovery of the link with the immunoregulatory human leukocyte antigen complex and the adverse events in relation to the H1N1 pandemic vaccines have shuffled the epidemiological numbers. Summary In this meta-review, we pooled incidence rates and prevalence rates reported in 30 countries or from 209 sets of data. Findings are reported per age, continent, and proxy race/ethnicity as well as period (i.e., before/after the pandemic). This meta-review showed that narcolepsy occurs in 0.87-1.21 of the world population, with specifically NT1 being investigated. Its pooled incidence rate in vaccinated samples is 1.58. There is furthermore an underreporting of narcolepsy in ethnic/race and gender minorities, of childhood narcolepsy type 2 and potential comorbid conditions masking the clinical complaints and hence timely diagnosis.
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Affiliation(s)
- Karen Spruyt
- School of Medicine, INSERM, University Claude Bernard, Lyon, France
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Barateau L, Dauvilliers Y. Recent advances in treatment for narcolepsy. Ther Adv Neurol Disord 2019; 12:1756286419875622. [PMID: 31632459 PMCID: PMC6767718 DOI: 10.1177/1756286419875622] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/21/2019] [Indexed: 11/17/2022] Open
Abstract
Narcolepsy type 1 (NT1) is a chronic orphan disorder, caused by the selective and irreversible loss of hypocretin/orexin (ORX) neurons, by a probable autoimmune process. Little is known about NT2 etiology and prevalence, sharing with NT1 excessive daytime sleepiness (EDS) and dysregulation of rapid eye movement (REM) sleep, but without cataplexy and loss of ORX neurons. Despite major advances in our understanding of the neurobiological basis of NT1, management remains nowadays only symptomatic. The main and most disabling symptom, EDS, is managed with psychostimulants, as modafinil/armodafinil, methylphenidate, or amphetamines as a third-line therapy. Narcolepsy is an active area for drug development, and new wake-promoting agents have been developed over the past years. Pitolisant, a selective histamine H3 receptor inverse agonist, has been recently approved to treat patients with NT1 and NT2. Solriamfetol, a phenylalanine derivative with dopaminergic and noradrenergic activity will be soon a new therapeutic option to treat EDS in NT1 and NT2. Sodium oxybate, used for decades in adult patients with narcolepsy, was recently shown to be effective and safe in childhood narcolepsy. The discovery of ORX deficiency in NT1 opened new therapeutic options oriented towards ORX-based therapies, especially nonpeptide ORX receptor agonists that are currently under development. In addition, immune-based therapies administered as early as possible after disease onset could theoretically slow down or stop the destruction of ORX neurons in some selected patients. Further well-designed controlled trials are required to determine if they could really impact on the natural history of the disease. Given the different clinical, biological and genetic profiles, narcolepsy may provide a nice example for developing personalized medicine in orphan diseases, that could ultimately aid in similar research and clinical efforts for other conditions.
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Affiliation(s)
- Lucie Barateau
- Service de Neurologie, Gui-de-Chauliac Hospital,
Montpellier, France; Sleep-Wake Disorders Center, Gui-de-Chauliac Hospital,
CHU Montpellier, France; National Reference Network for Narcolepsy,
Montpellier, France; Inserm U1061, Montpellier, France
| | - Yves Dauvilliers
- Service de Neurologie, Gui-de-Chauliac Hospital,
CHU Montpellier, 80 avenue Augustin Fliche, 34295 Montpellier Cedex 5,
France
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