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Cross MR, Savitz ST, Sangaralingham LR, So EL, Ackerman MJ, Noseworthy PA. Sudden Cardiac Death or Ventricular Arrythmia in Patients Taking Levetiracetam or Oxcarbazepine. Neurology 2024; 102:e209177. [PMID: 38560823 DOI: 10.1212/wnl.0000000000209177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 01/05/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Levetiracetam is a widely used antiseizure medication. Recent concerns have been raised regarding the potential prolongation of the QT interval by levetiracetam and increased risk of sudden cardiac death. This could have profound implications for patient safety and for prescribing practice. This study assessed the potential association of levetiracetam with cardiac outcomes related to QT interval prolongation. We compared outcomes of patients taking levetiracetam with those taking oxcarbazepine as a comparator medication that has not been associated with prolongation of the QT interval. METHODS The sample included patients who were newly prescribed levetiracetam or oxcarbazepine from January 31, 2010, to December 31, 2019, using administrative claims data from the OptumLabs Data Warehouse (OLDW). The analysis focused on a combined endpoint of sudden cardiac death or ventricular arrythmia, which are both linked to QT interval prolongation. We used a new user design and selected oxcarbazepine as an active comparator with levetiracetam to minimize bias. We used propensity score weighting to balance the levetiracetam and oxcarbazepine cohorts and then performed weighted Cox regressions to evaluate the association of levetiracetam with the combined endpoint. RESULTS We identified 104,655 enrollees taking levetiracetam and 39,596 enrollees taking oxcarbazepine. At baseline, enrollees taking levetiracetam were older, more likely to have diagnosed epilepsy, and more likely to have diagnosed comorbidities including hypertension, cerebrovascular disease, and coronary artery disease. In the main analysis, we found no significant difference between levetiracetam and oxcarbazepine in the rate of the combined endpoint for the Cox proportional hazards model (hazard ratio [HR] 0.79, 95% CI 0.42-1.47) or Cox regression with time-varying characteristics (HR 0.78, 95% CI 0.41-1.50). DISCUSSION When compared with oxcarbazepine, levetiracetam does not correlate with increased risk of ventricular arrythmia and sudden cardiac death. Our finding does not support the concern for cardiac risk to indicate restriction of levetiracetam use nor the requirement of cardiac monitoring when using it. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that sudden cardiac death and ventricular arrythmia are not more frequent in patients older than 17 years newly prescribed levetiracetam, compared with those prescribed oxcarbazepine.
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Affiliation(s)
- Madeline R Cross
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Samuel T Savitz
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Elson L So
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Michael J Ackerman
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
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Shah RA, Chahal CAA, Ranjha S, Sharaf Dabbagh G, Asatryan B, Limongelli I, Khanji M, Ricci F, De Paoli F, Zucca S, Tristani-Firouzi M, St Louis EK, So EL, Somers VK. Cardiovascular Disease Burden, Mortality, and Sudden Death Risk in Epilepsy: A UK Biobank Study. Can J Cardiol 2024; 40:688-695. [PMID: 38013064 DOI: 10.1016/j.cjca.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Sudden death is the leading cause of mortality in medically refractory epilepsy. Middle-aged persons with epilepsy (PWE) are under investigated regarding their mortality risk and burden of cardiovascular disease (CVD). METHODS Using UK Biobank, we identified 7786 (1.6%) participants with diagnoses of epilepsy and 6,171,803 person-years of follow-up (mean 12.30 years, standard deviation 1.74); 566 patients with previous histories of stroke were excluded. The 7220 PWE comprised the study cohort with the remaining 494,676 without epilepsy as the comparator group. Prevalence of CVD was determined using validated diagnostic codes. Cox proportional hazards regression was used to assess all-cause mortality and sudden death risk. RESULTS Hypertension, coronary artery disease, heart failure, valvular heart disease, and congenital heart disease were more prevalent in PWE. Arrhythmias including atrial fibrillation/flutter (12.2% vs 6.9%; P < 0.01), bradyarrhythmias (7.7% vs 3.5%; P < 0.01), conduction defects (6.1% vs 2.6%; P < 0.01), and ventricular arrhythmias (2.3% vs 1.0%; P < 0.01), as well as cardiac implantable electric devices (4.6% vs 2.0%; P < 0.01) were more prevalent in PWE. PWE had higher adjusted all-cause mortality (hazard ratio [HR], 3.9; 95% confidence interval [CI], 3.01-3.39), and sudden death-specific mortality (HR, 6.65; 95% CI, 4.53-9.77); and were almost 2 years younger at death (68.1 vs 69.8; P < 0.001). CONCLUSIONS Middle-aged PWE have increased all-cause and sudden death-specific mortality and higher burden of CVD including arrhythmias and heart failure. Further work is required to elucidate mechanisms underlying all-cause mortality and sudden death risk in PWE of middle age, to identify prognostic biomarkers and develop preventative therapies in PWE.
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Affiliation(s)
- Ravi A Shah
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - C Anwar A Chahal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota, USA; WellSpan Center for Inherited Cardiovascular Diseases, WellSpan Health, York, Pennsylvania, USA.
| | | | - Ghaith Sharaf Dabbagh
- WellSpan Center for Inherited Cardiovascular Diseases, WellSpan Health, York, Pennsylvania, USA; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Babken Asatryan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Mohammed Khanji
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom; NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | | | | | - Erik K St Louis
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA; Mayo Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elson L So
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Virend K Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Cox BC, Khattak JF, Starnes K, Brinkmann BH, Tatum WO, Noe KH, Van Gompel JJ, Miller KJ, Marsh WR, Grewal SS, Zimmerman RS, So EL, Wong-Kisiel LC, Burkholder DB. Subclinical seizures on stereotactic EEG: characteristics and prognostic value. Seizure 2022; 101:96-102. [DOI: 10.1016/j.seizure.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/14/2022] [Accepted: 07/24/2022] [Indexed: 12/01/2022] Open
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Chahal CAA, Tester DJ, Fayyaz AU, Jaliparthy K, Khan NA, Lu D, Khan M, Sahoo A, Rajendran A, Knight JA, Simpson MA, Behr ER, So EL, St. Louis EK, Reichard RR, Edwards WD, Ackerman MJ, Somers VK. Confirmation of Cause of Death Via Comprehensive Autopsy and Whole Exome Molecular Sequencing in People With Epilepsy and Sudden Unexpected Death. J Am Heart Assoc 2021; 10:e021170. [PMID: 34816733 PMCID: PMC9075361 DOI: 10.1161/jaha.121.021170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Sudden cardiac arrest is the leading mode of death in the United States. Epilepsy affects 1% of Americans; yet epidemiological data show a prevalence of 4% in cases of sudden cardiac arrest. Sudden unexpected death in epilepsy (SUDEP) may share features with sudden cardiac arrest. The objective of this study was to report autopsy and genomic findings in a large cohort of SUDEP cases. Methods and Results Mayo Clinic Sudden Death Registry containing cases (ages 0–90 years) of sudden unexpected and unexplained deaths 1960 to present was queried. Exome sequencing performed on decedent cases. From 13 687 cases of sudden death, 656 (4.8%) had a history of seizures, including 368 confirmed by electroencephalography, 96 classified as SUDEP, 58 as non‐SUDEP, and 214 as unknown (insufficient records). Mean age of death in SUDEP was 37 (±19.7) years; 56 (58.3%) were male; 65% of deaths occurred at night; 54% were found in bed; and 80.6% were prone. Autopsies were obtained in 83 cases; bystander coronary artery disease was frequently reported as cause of death; nonspecific fibrosis was seen in 32.6% of cases, in structurally normal hearts. There were 4 cases of Dravet syndrome with pathogenic variants in SCN1A gene. Using whole exome sequencing in 11 cases, 18 ultrarare nonsynonymous variants were identified in 6 cases including CACNB2, RYR2, CLNB, CACNA1H, and CLCN2. Conclusions This study examined one of the largest single‐center US series of SUDEP cases. Several cases were reclassified as SUDEP, 15% had an ECG when alive, and 11 (11.4%) had blood for whole exome sequencing analysis. The most frequent antemortem genetic finding was pathogenic variants in SCN1A; postmortem whole exome sequencing identified 18 ultrarare variants.
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Affiliation(s)
- C. Anwar A. Chahal
- Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterMN
- WellSpan Center for Inherited Cardiovascular DiseasesWellSpan HealthPA
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Division of CardiologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - David J. Tester
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Department of Molecular Pharmacology & Experimental TherapeuticsWindland Smith Rice Sudden Death Genomic LaboratoryMayo ClinicRochesterMN
| | - Ahmed U. Fayyaz
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Department of Laboratory Medicine & PathologyMayo ClinicRochesterMN
| | - Keerthi Jaliparthy
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Department of MedicineMayo ClinicRochesterMN
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
| | | | - Dongmei Lu
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
| | - Mariha Khan
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | | | | | | | | | - Elijah R. Behr
- Cardiology Section and Cardiovascular Clinical Academic GroupSt George’s, University of LondonLondonUnited Kingdom
- St George’s University Hospitals’ NHS Foundation TrustLondonUnited Kingdom
| | - Elson L. So
- Department of NeurologyMayo ClinicRochesterMN
| | - Erik K. St. Louis
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of NeurologyMayo ClinicRochesterMN
- Mayo Center for Sleep MedicineMayo ClinicRochesterMN
| | - R. Ross Reichard
- Department of Laboratory Medicine & PathologyMayo ClinicRochesterMN
| | | | | | - Virend K. Somers
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
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Chahal CAA, Gottwald JA, St Louis EK, Xie J, Brady PA, Alhurani RE, Timm P, Thapa P, Mandrekar J, So EL, Olson JE, Ackerman MJ, Somers VK. QT prolongation in patients with index evaluation for seizure or epilepsy is predictive of all-cause mortality. Heart Rhythm 2021; 19:578-584. [PMID: 34775068 DOI: 10.1016/j.hrthm.2021.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Refractory epilepsy confers a considerable lifetime risk of sudden unexplained death in epilepsy (SUDEP). Mechanisms may overlap with sudden cardiac death (SCD), particularly regarding QTc prolongation. Guidelines in the United States do not mandate the use of electrocardiography (ECG) in diagnostic evaluation of seizures or epilepsy. OBJECTIVE The purpose of this study was to determine the frequency of ECG use and of QT prolongation, and whether QT prolongation predicts mortality in patients with seizures. METHODS We performed a retrospective cohort study including all patients seen at Mayo Clinic in Rochester, Minnesota, from January 1, 2000, to July 31, 2015, with index evaluation for seizure or epilepsy. Patients with an ECG were categorized by the presence of a prolonged QT interval with a primary endpoint of all-cause mortality after the 15-year observation period. RESULTS Optimal cutoff QT intervals most predictive of mortality were identified. Median age was 40.0 years. An ECG was obtained in 18,222 patients (57.4%). After patients with confounding ECG findings were excluded, primary prolonged QT intervals were seen in 223 cases (1.4%), similar to the general population. Kaplan-Meier analysis demonstrated a significant increase in mortality (Cox hazard ratio [HR] 1.90; 95% confidence interval [CI] 1.76-2.05) for prolonged optimal cutoff QT, maintained after adjustments for age, Charlson comorbidity index, and sex (HR 1.48; 95% CI 1.37-1.59). CONCLUSION Use of ECG in diagnostic workup of patients with seizures is poor. A prolonged optimal cutoff QTc interval predicts all-cause mortality in patients evaluated for seizure and those diagnosed with epilepsy. We advocate the routine use of a 12-lead ECG at index evaluation in patients with seizure or epilepsy.
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Affiliation(s)
- C Anwar A Chahal
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Erik K St Louis
- Department of Neurology, Mayo Clinic, Rochester, Minnesota; Mayo Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jiang Xie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter A Brady
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rabe E Alhurani
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Neurology, Mayo Clinic, Rochester, Minnesota; Division of Geriatric Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Paul Timm
- Department of Neurology, Mayo Clinic, Rochester, Minnesota; Mayo Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Department of Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jay Mandrekar
- Division of Biomedical Statistics and Informatics, Department of Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Elson L So
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Janet E Olson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Michael J Ackerman
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Virend K Somers
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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So EL, Hoffman EM. Cerebral Function Monitoring and Cortical Mapping for Nonepilepsy Surgery. Clin Neurophysiol 2021. [DOI: 10.1093/med/9780190067854.003.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
The purpose of intraoperative neurophysiological monitoring is to optimize postsurgical outcome by guiding the course of surgery. This chapter critically examines the principles and applications of different neurophysiological monitoring techniques in nonepilepsy surgeries. For some time, the use of electroencephalography has been widely established for carotid endarterectomy and cardiac surgery. Other modalities of neurophysiological monitoring have emerged, such as somatosensory evoked potentials (SSEPs), carotid stump pressure measurement, transcranial Doppler, and near-infrared spectrophotometry. More recent studies in the literature compared the yield of some of these techniques. A few studies suggested the usefulness of monitoring surgery with a combination of modalities. This chapter also examines the technical and clinical aspects of neurophysiological monitoring during surgical resection of brain lesions, such as tumors and vascular malformations. When the lesion is near eloquent cortex, electrical stimulation mapping of the cortex and SSEPs are used to guide surgical resection in order to maximize the extent of the resection and minimize the risk of impairing critical cortical functions such as language and motor functions.
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Hirsch LJ, Fong MW, Leitinger M, LaRoche SM, Beniczky S, Abend NS, Lee JW, Wusthoff CJ, Hahn CD, Westover MB, Gerard EE, Herman ST, Haider HA, Osman G, Rodriguez-Ruiz A, Maciel CB, Gilmore EJ, Fernandez A, Rosenthal ES, Claassen J, Husain AM, Yoo JY, So EL, Kaplan PW, Nuwer MR, van Putten M, Sutter R, Drislane FW, Trinka E, Gaspard N. American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology: 2021 Version. J Clin Neurophysiol 2021; 38:1-29. [PMID: 33475321 PMCID: PMC8135051 DOI: 10.1097/wnp.0000000000000806] [Citation(s) in RCA: 308] [Impact Index Per Article: 102.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lawrence J. Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael W.K. Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Suzette M. LaRoche
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Center, Dianalund and Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jong Woo Lee
- Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A
| | | | - Cecil D. Hahn
- Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Elizabeth E. Gerard
- Comprehensive Epilepsy Center, Department of Neurology, Northwestern University, Chicago, Illinois, U.S.A
| | | | - Hiba Arif Haider
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Gamaleldin Osman
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan, U.S.A
| | - Andres Rodriguez-Ruiz
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Carolina B. Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Emily J. Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jan Claassen
- Neurocritical Care, Department of Neurology, Columbia University, New York, New York, U.S.A
| | - Aatif M. Husain
- Department of Medicine (Neurology), Duke University Medical Center, and Veterans Affairs Medical Center, Durham, North Carolina, U.S.A
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Elson L. So
- Division of Epilepsy, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Marc R. Nuwer
- Department of Neurology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, U.S.A
| | - Michel van Putten
- Medisch Spectrum Twente and University of Twente, Enschede, The Netherlands
| | - Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Frank W. Drislane
- Department of Neurology, Harvard Medical School, and Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Nicolas Gaspard
- Department of Neurology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
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Chahal CAA, Salloum MN, Alahdab F, Gottwald JA, Tester DJ, Anwer LA, So EL, Murad MH, St Louis EK, Ackerman MJ, Somers VK. Systematic Review of the Genetics of Sudden Unexpected Death in Epilepsy: Potential Overlap With Sudden Cardiac Death and Arrhythmia-Related Genes. J Am Heart Assoc 2020; 9:e012264. [PMID: 31865891 PMCID: PMC6988156 DOI: 10.1161/jaha.119.012264] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 09/25/2019] [Indexed: 12/29/2022]
Abstract
Background Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death. SUDEP shares many features with sudden cardiac death and sudden unexplained death in the young and may have a similar genetic contribution. We aim to systematically review the literature on the genetics of SUDEP. Methods and Results PubMed, MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus were searched through April 4, 2017. English language human studies analyzing SUDEP for known sudden death, ion channel and arrhythmia-related pathogenic variants, novel variant discovery, and copy number variant analyses were included. Aggregate descriptive statistics were generated; data were insufficient for meta-analysis. A total of 8 studies with 161 unique individuals were included; mean was age 29.0 (±SD 14.2) years; 61% males; ECG data were reported in 7.5% of cases; 50.7% were found prone and 58% of deaths were nocturnal. Cause included all types of epilepsy. Antemortem diagnosis of Dravet syndrome and autism (with duplication of chromosome 15) was associated with 11% and 9% of cases. The most frequently detected known pathogenic variants at postmortem were in Na+ and K+ ion channel subunits, as were novel potentially pathogenic variants (11%). Overall, the majority of variants were of unknown significance. Analysis of copy number variant was insignificant. Conclusions SUDEP case adjudication and evaluation remains limited largely because of crucial missing data such as ECGs. The most frequent pathogenic/likely pathogenic variants identified by molecular autopsy are in ion channel or arrhythmia-related genes, with an ≈11% discovery rate. Comprehensive postmortem examination should include examination of the heart and brain by specialized pathologists and blood storage.
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Affiliation(s)
- C. Anwar A. Chahal
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Mohammad N. Salloum
- Internal MedicineIcahn School of Medicine at Mount SinaiQueens Hospital CenterNew YorkNY
| | - Fares Alahdab
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
- Division of Preventive, Occupational and Aerospace MedicineMayo ClinicRochesterMN
| | | | - David J. Tester
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Windland Smith Rice Sudden Death Genomics LaboratoryMayo ClinicRochesterMN
| | - Lucman A. Anwer
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular SurgeryMayo ClinicRochesterMN
- General SurgeryUIC/MGHChicagoIL
| | - Elson L. So
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
| | - Mohammad Hassan Murad
- Evidence‐Based Practice Research ProgramMayo ClinicRochesterMN
- Division of Preventive, Occupational and Aerospace MedicineMayo ClinicRochesterMN
| | - Erik K. St Louis
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of NeurologyMayo ClinicRochesterMN
- Mayo Center for Sleep MedicineMayo ClinicRochesterMN
| | - Michael J. Ackerman
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Windland Smith Rice Sudden Death Genomics LaboratoryMayo ClinicRochesterMN
- Department of PediatricsMayo ClinicRochesterMN
| | - Virend K. Somers
- Mayo Clinic College of MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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McCarter AR, Timm PC, Shepard PW, Sandness DJ, Luu T, McCarter SJ, Dueffert L, Dresow M, Feemster JC, Cascino GD, So EL, Worrell GA, Britton JW, Sherif A, Jaliparthy K, Chahal AA, Somers VK, St Louis EK. Obstructive sleep apnea in refractory epilepsy: A pilot study investigating frequency, clinical features, and association with risk of sudden unexpected death in epilepsy. Epilepsia 2018; 59:1973-1981. [PMID: 30246243 DOI: 10.1111/epi.14548] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/18/2018] [Accepted: 07/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We aimed to determine the frequency of probable obstructive sleep apnea (pOSA) in refractory epilepsy monitoring unit inpatients and clinical features associated with pOSA, including risk for sudden unexpected death in epilepsy (SUDEP). METHODS We prospectively recruited 49 consecutive adult patients admitted to the Mayo Clinic Epilepsy Monitoring Unit with focal, generalized, or unclassified epilepsy syndromes. pOSA was identified using oximetric oxyhemoglobin desaturation index (ODI) and the Sleep Apnea-Sleep Disorders Questionnaire (SA-SDQ) and STOP-BAG screening tools. Revised SUDEP Risk Inventory (rSUDEP-7) scores were calculated, and epilepsy patients with and without pOSA were compared with Wilcoxon signed-rank tests. Correlation and regression analyses were utilized to determine relationships between pOSA and rSUDEP-7 scores. RESULTS Thirty-five percent of patients had pOSA, with a mean ODI of 11.3 ± 5.1/h (range = 5.1-22.8). Patients with pOSA were older and heavier, and more frequently had a focal epilepsy syndrome and longer epilepsy duration, with higher SA-SDQ and STOP-BAG scores (all P < 0.05). Median rSUDEP-7 score was 3 ± 1.4 (range = 0-6). Higher rSUDEP-7 scores were positively correlated with higher ODI (P = 0.036). rSUDEP-7 score ≥ 5 was associated with pOSA by ODI, SA-SDQ, and STOP-BAG questionnaire criteria (P < 0.05). SIGNIFICANCE Our pilot study identified a high frequency of pOSA in refractory epilepsy monitoring patients, finding that pOSA patients were older and heavier, with higher screening symptoms for sleep apnea and more frequent focal seizures with a longer epilepsy duration. We also found a possible association between OSA and SUDEP risk. Identification and treatment of OSA in patients with epilepsy could conceivably provide a novel approach toward preventing the risk of SUDEP. Future studies with polysomnography are needed to confirm predictive features for OSA in epilepsy populations, and to determine whether OSA is associated with SUDEP risk.
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Affiliation(s)
- Allison R McCarter
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Paul C Timm
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Paul W Shepard
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - David J Sandness
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Thao Luu
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Stuart J McCarter
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.,Department of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.,Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Lucas Dueffert
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Max Dresow
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - John C Feemster
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Gregory D Cascino
- Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Elson L So
- Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Gregory A Worrell
- Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Jeffrey W Britton
- Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Akil Sherif
- Department of Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Keerthi Jaliparthy
- Department of Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Anwar A Chahal
- Department of Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota.,Mayo Graduate School of Biomedical Sciences, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Virend K Somers
- Department of Cardiology, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Erik K St Louis
- Mayo Center for Sleep Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.,Department of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota.,Department of Neurology, Mayo Clinic and Foundation, Rochester, Minnesota
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Ryvlin P, So EL, Gordon CM, Hesdorffer DC, Sperling MR, Devinsky O, Bunker MT, Olin B, Friedman D. Long-term surveillance of SUDEP in drug-resistant epilepsy patients treated with VNS therapy. Epilepsia 2018; 59:562-572. [DOI: 10.1111/epi.14002] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Philippe Ryvlin
- Department of Clinical Neurosciences; Vaud University Hospital; Lausanne Switzerland
- Epilepsy Institute (Institut Des ÉpilepsiEs; IDÉE); Lyon France
| | - Elson L. So
- Department of Neurology; Mayo Clinic; Rochester MN USA
| | | | | | - Michael R. Sperling
- Department of Neurology; Jefferson Comprehensive Epilepsy Center; Thomas Jefferson University; Philadelphia PA USA
| | - Orrin Devinsky
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
| | | | - Bryan Olin
- Cyberonics, Inc. (LivaNova, PLC); Houston TX USA
| | - Daniel Friedman
- Department of Neurology; Comprehensive Epilepsy Center; New York University Langone Medical Center; New York NY USA
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11
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Burkholder DB, Jones AL, Jones DT, Fabris RR, Britton JW, Lagerlund TD, So EL, Cascino GD, Worrell GA, Shin C, St Louis EK. Frequent sleep-related bitemporal focal seizures in transient epileptic amnesia syndrome: Evidence from ictal video-EEG. Epilepsia Open 2017; 2:255-259. [PMID: 29588954 PMCID: PMC5719851 DOI: 10.1002/epi4.12040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/07/2022] Open
Abstract
Two patients who shared similar presenting clinical features of anterograde and retrograde autobiographical amnesia typical of transient epileptic amnesia (TEA) underwent prolonged video electroencephalogram (VEEG) monitoring and were found to have sleep-activated epileptiform activity and frequent subclinical bitemporal seizures predominantly during sleep. Case 1 is a 59-year-old woman whose presenting complaint was memory impairment. Over 18 months, she had three distinct 8-h-long episodes of confusion and disorientation with persistent anterograde and retrograde autobiographical amnesia. VEEG recorded frequent interictal bitemporal sharp waves confined to sleep, and 14 subclinical seizures, also mostly during sleep. Case 2 is a 50-year-old woman with known focal epilepsy also presented with memory complaints. Over the course of 1 year, she had two discrete 2-h-long episodes of amnesia, with ongoing anterograde and retrograde autobiographical amnesia. VEEG recorded independent bitemporal sharp waves, and 14 subclinical seizures during sleep and drowsiness. Memory impairment improved in both patients with successful treatment of their seizures. Although the etiology of accelerated long-term forgetting (ALF) and remote memory impairment (RMI) in transient epileptic amnesia (TEA) is unknown, these cases suggest frequent sleep-related seizures may contribute, and they highlight the importance of video-EEG monitoring.
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Affiliation(s)
- David B Burkholder
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Amy L Jones
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - David T Jones
- Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Rachel R Fabris
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Spectrum Health Medical Group Rockford Michigan U.S.A
| | - Jeffrey W Britton
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Terrence D Lagerlund
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Elson L So
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Gregory D Cascino
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Gregory A Worrell
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Cheolsu Shin
- Mayo Clinic Comprehensive Epilepsy Program Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A
| | - Erik K St Louis
- Department of Neurology Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Mayo Center for Sleep Medicine Mayo Clinic College of Medicine Rochester Minnesota U.S.A.,Department of Medicine Mayo Clinic College of Medicine Rochester Minnesota U.S.A
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Affiliation(s)
- Anteneh M Feyissa
- From the Departments of Neurology (A.M.F., C.S., E.L.S.), Child and Adolescent Neurology (D.L.K.-J.), and Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, Rochester, MN.
| | - Daniel L Kenney-Jung
- From the Departments of Neurology (A.M.F., C.S., E.L.S.), Child and Adolescent Neurology (D.L.K.-J.), and Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, Rochester, MN
| | - Cheolsu Shin
- From the Departments of Neurology (A.M.F., C.S., E.L.S.), Child and Adolescent Neurology (D.L.K.-J.), and Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, Rochester, MN
| | - John C Cheville
- From the Departments of Neurology (A.M.F., C.S., E.L.S.), Child and Adolescent Neurology (D.L.K.-J.), and Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, Rochester, MN
| | - Elson L So
- From the Departments of Neurology (A.M.F., C.S., E.L.S.), Child and Adolescent Neurology (D.L.K.-J.), and Laboratory Medicine and Pathology (J.C.C.), Mayo Clinic, Rochester, MN
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13
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Burkholder DB, Britton JW, Rajasekaran V, Fabris RR, Cherian PJ, Kelly-Williams KM, So EL, Nickels KC, Wong-Kisiel LC, Lagerlund TD, Cascino GD, Worrell GA, Wirrell EC. Routine vs extended outpatient EEG for the detection of interictal epileptiform discharges. Neurology 2016; 86:1524-30. [PMID: 26984946 DOI: 10.1212/wnl.0000000000002592] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/13/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the yield of epileptiform abnormalities on 30-minute recordings with those greater than 45 minutes. METHODS We performed a prospective observational cross-sectional study of all outpatient routine EEGs comparing the rate of interictal epileptiform discharges (IEDs) and clinical events during the initial 30 minutes (routine) with those occurring in the remaining 30-60 minutes (extended). A relative increase of 10% was considered clinically significant. RESULTS EEGs from 1,803 patients were included; overall EEG duration was 59.4 minutes (SD ±6.5). Of 426 patients with IEDs at any time during the EEG, 81 (19.1%, 95% confidence interval 15.6-23) occurred only after the initial 30 minutes. The rate of late IEDs was not associated with age, indication, IED type, or sleep deprivation. Longer recording times also increased event capture rate by approximately 30%. CONCLUSIONS The yield of IED and event detection is increased in extended outpatient EEGs compared to 30-minute studies.
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Affiliation(s)
- David B Burkholder
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina.
| | - Jeffrey W Britton
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Vijayalakshmi Rajasekaran
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Rachel R Fabris
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Perumpillichira J Cherian
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Kristen M Kelly-Williams
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Elson L So
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Katherine C Nickels
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Lily C Wong-Kisiel
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Terrence D Lagerlund
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Gregory D Cascino
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Gregory A Worrell
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
| | - Elaine C Wirrell
- From the Departments of Neurology (D.B.B., J.W.B., V.R., R.R.F., K.M.K.-W., E.L.S., T.D.L., G.D.C., G.A.W.) and Child and Adolescent Neurology (P.J.C., K.C.N., L.C.W.-K., E.C.W.), Division of Epilepsy, Mayo Clinic, Rochester, MN; Department of Neurology (V.R.), Baylor Scott and White Health, Temple, TX; Department of Neurology (V.R.), West Virginia University Health Science Center, Morgantown; Spectrum Medical Group (R.R.F.), Rockford, MI; Division of Neurology (P.J.C.), McMaster University, Hamilton, Canada; and Minneapolis Clinic of Neurology (K.M.K.-W.), Edina
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Abstract
Many electrophysiological assessment and techniques of clinical neurophysiology can be used in the assessment of patients with suspected disease of the central nervous system. Each of the techniques is applied either to assist clinicians in assessing disease of the central nervous system or, less commonly, to monitor changes in neural function. These techniques can be used to monitor neural function in observing progression of disease, such as the frequency of seizures, or improvement in a patient’s condition with specific treatment. They are also used in the intensive care unit and operating room to identify progressive neural damage. The clinical neurophysiological testing technique that is most appropriate for a patient depends on the clinical problem, and, often, some combination of techniques best provides the necessary data. This chapter focuses on the application of clinical neurophysiological techniques in assessing patients with suspected central nervous system disorders.
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Abstract
This chapter covers the pitfalls and benefits of recording electrophysiological data in challenging environments such the operating room or intensive care unit. The usefulness of such recordings depends on the knowledge and skills of the technologist and the neurophysiologist, who should be able to correct technical problems and recognize electrophysiological changes indicating nervous system injury. Parameters of actionable EEG changes are discussed, because the degree of EEG change encountered during surgery varies widely. EEG monitoring during carotid artery surgery is compared with other methods of monitoring, such as evoked potentials or neurological examination during wakefulness. This chapter also discusses the pharmacological effects of anesthesia on the EEG. These effects constitute the background EEG activity from which the critical EEG changes appear. It is important that these anesthesia effects on the EEG not be mistaken for pathological changes due to the surgical procedure.
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Burkholder DB, Sulc V, Hoffman EM, Cascino GD, Britton JW, So EL, Marsh WR, Meyer FB, Van Gompel JJ, Giannini C, Wass CT, Watson RE, Worrell GA. Interictal scalp electroencephalography and intraoperative electrocorticography in magnetic resonance imaging-negative temporal lobe epilepsy surgery. JAMA Neurol 2014; 71:702-9. [PMID: 24781216 DOI: 10.1001/jamaneurol.2014.585] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Scalp electroencephalography (EEG) and intraoperative electrocorticography (ECoG) are routinely used in the evaluation of magnetic resonance imaging-negative temporal lobe epilepsy (TLE) undergoing standard anterior temporal lobectomy with amygdalohippocampectomy (ATL), but the utility of interictal epileptiform discharge (IED) identification and its role in outcome are poorly defined. OBJECTIVES To determine whether the following are associated with surgical outcomes in patients with magnetic resonance imaging-negative TLE who underwent standard ATL: (1) unilateral-only IEDs on preoperative scalp EEG; (2) complete resection of tissue generating IEDs on ECoG; (3) complete resection of opioid-induced IEDs recorded on ECoG; and (4) location of IEDs recorded on ECoG. DESIGN, SETTING, AND PARTICIPANTS Data were gathered through retrospective medical record review at a tertiary referral center. Adult and pediatric patients with TLE who underwent standard ATL between January 1, 1990, and October 15, 2010, were considered for inclusion. Inclusion criteria were magnetic resonance imaging-negative TLE, standard ECoG performed at the time of surgery, and a minimum follow-up of 12 months. Univariate analysis was performed using log-rank time-to-event analysis. Variables reaching significance with log-rank testing were further analyzed using Cox proportional hazards. MAIN OUTCOMES AND MEASURES Excellent or nonexcellent outcome at time of last follow-up. An excellent outcome was defined as Engel class I and a nonexcellent outcome as Engel classes II through IV. RESULTS Eighty-seven patients met inclusion criteria, with 48 (55%) achieving an excellent outcome following ATL. Unilateral IEDs on scalp EEG (P = .001) and complete resection of brain regions generating IEDs on baseline intraoperative ECoG (P = .02) were associated with excellent outcomes in univariate analysis. Both were associated with excellent outcomes when analyzed with Cox proportional hazards (unilateral-only IEDs, relative risk = 0.31 [95% CI, 0.16-0.64]; complete resection of IEDs on baseline ECoG, relative risk = 0.39 [95% CI, 0.20-0.76]). Overall, 25 of 35 patients (71%) with both unilateral-only IEDs and complete resection of baseline ECoG IEDs had an excellent outcome. CONCLUSIONS AND RELEVANCE Unilateral-only IEDs on preoperative scalp EEG and complete resection of IEDs on baseline ECoG are associated with better outcomes following standard ATL in magnetic resonance imaging-negative TLE. Prospective evaluation is needed to clarify the use of ECoG in tailoring temporal lobectomy.
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Affiliation(s)
| | - Vlastimil Sulc
- Department of Neurology, Mayo Clinic, Rochester, Minnesota2International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | | | | | | | - Elson L So
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - W Richard Marsh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - C Thomas Wass
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | | | - Gregory A Worrell
- Department of Neurology, Mayo Clinic, Rochester, Minnesota7Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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17
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Sulc V, Stykel S, Hanson DP, Brinkmann BH, Jones DT, Holmes DR, Robb RA, Senjem ML, Mullan BP, Watson RE, Horinek D, Cascino GD, Wong-Kisiel LC, Britton JW, So EL, Worrell GA. Statistical SPECT processing in MRI-negative epilepsy surgery. Neurology 2014; 82:932-9. [PMID: 24532274 DOI: 10.1212/wnl.0000000000000209] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the benefit of statistical SPECT processing over traditional subtraction methods, we compared ictal-interictal SPECT analyzed by statistical parametric mapping (SPM) (ISAS), statistical ictal SPECT coregistered to MRI (STATISCOM), and subtraction ictal-interictal SPECT coregistered with MRI (SISCOM) in patients with MRI-negative focal temporal lobe epilepsy (nTLE) and extratemporal lobe epilepsy (nETLE). METHODS We retrospectively identified 49 consecutive cases of drug-resistant focal epilepsy that had a negative preoperative MRI and underwent interictal and ictal SPECT prior to resective epilepsy surgery. Interictal and ictal SPECT scans were analyzed using SISCOM, ISAS, and STATISCOM to create hyperperfusion and hypoperfusion maps for each patient. Reviewers blinded to clinical data and the SPECT analysis method marked the site of probable seizure origin and indicated their confidence in the localization. RESULTS In nTLE and nETLE, the hyperperfusions detected by STATISCOM (71% nTLE, 57% nETLE) and ISAS (67% nTLE, 53% nETLE) were more often colocalized with surgery resection site compared to SISCOM (38% nTLE, 36% nETLE). In nTLE, localization of the hyperperfusion to the region of surgery was associated with an excellent outcome for STATISCOM (p = 0.005) and ISAS (p = 0.027), but not in SISCOM (p = 0.071). This association was not present in nETLE for any method. CONCLUSION In an unselected group of patients with normal MRI and focal epilepsy, SPM-based methods of SPECT processing showed better localization of SPECT hyperperfusion to surgical resection site and higher interobserver agreement compared to SISCOM. These results show the benefit of statistical SPECT processing methods and further highlight the challenge of nETLE.
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Affiliation(s)
- Vlastimil Sulc
- From the Departments of Neurology (V.S., B.H.B., D.T.J., G.D.C., L.C.W.-K., J.W.B., E.L.S., G.A.W.) and Radiology (M.L.S., B.P.M., R.E.W.) and Biomedical Imaging Resource (S.S., D.P.H., D.R.H., R.A.R.), Mayo Clinic, Rochester, MN; International Clinical Research Center (V.S., D.H.), St. Anne's University Hospital, Brno; and the Department of Neurology (V.S.), 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
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Ryvlin P, Nashef L, Lhatoo SD, Bateman LM, Bird J, Bleasel A, Boon P, Crespel A, Dworetzky BA, Høgenhaven H, Lerche H, Maillard L, Malter MP, Marchal C, Murthy JMK, Nitsche M, Pataraia E, Rabben T, Rheims S, Sadzot B, Schulze-Bonhage A, Seyal M, So EL, Spitz M, Szucs A, Tan M, Tao JX, Tomson T. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol 2013; 12:966-77. [PMID: 24012372 DOI: 10.1016/s1474-4422(13)70214-x] [Citation(s) in RCA: 686] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in people with chronic refractory epilepsy. Very rarely, SUDEP occurs in epilepsy monitoring units, providing highly informative data for its still elusive pathophysiology. The MORTEMUS study expanded these data through comprehensive evaluation of cardiorespiratory arrests encountered in epilepsy monitoring units worldwide. METHODS Between Jan 1, 2008, and Dec 29, 2009, we did a systematic retrospective survey of epilepsy monitoring units located in Europe, Israel, Australia, and New Zealand, to retrieve data for all cardiorespiratory arrests recorded in these units and estimate their incidence. Epilepsy monitoring units from other regions were invited to report similar cases to further explore the mechanisms. An expert panel reviewed data, including video electroencephalogram (VEEG) and electrocardiogram material at the time of cardiorespiratory arrests whenever available. FINDINGS 147 (92%) of 160 units responded to the survey. 29 cardiorespiratory arrests, including 16 SUDEP (14 at night), nine near SUDEP, and four deaths from other causes, were reported. Cardiorespiratory data, available for ten cases of SUDEP, showed a consistent and previously unrecognised pattern whereby rapid breathing (18-50 breaths per min) developed after secondary generalised tonic-clonic seizure, followed within 3 min by transient or terminal cardiorespiratory dysfunction. Where transient, this dysfunction later recurred with terminal apnoea occurring within 11 min of the end of the seizure, followed by cardiac arrest. SUDEP incidence in adult epilepsy monitoring units was 5·1 (95% CI 2·6-9·2) per 1000 patient-years, with a risk of 1·2 (0·6-2·1) per 10,000 VEEG monitorings, probably aggravated by suboptimum supervision and possibly by antiepileptic drug withdrawal. INTERPRETATION SUDEP in epilepsy monitoring units primarily follows an early postictal, centrally mediated, severe alteration of respiratory and cardiac function induced by generalised tonic-clonic seizure, leading to immediate death or a short period of partly restored cardiorespiratory function followed by terminal apnoea then cardiac arrest. Improved supervision is warranted in epilepsy monitoring units, in particular during night time. FUNDING Commission of European Affairs of the International League Against Epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Hospices Civils de Lyon and CRNL, INSERM U1028, CNRS 5292, Lyon, France.
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Affiliation(s)
- Elson L So
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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Brinkmann BH, Jones DT, Stead M, Kazemi N, O'Brien TJ, So EL, Blumenfeld H, Mullan BP, Worrell GA. Statistical parametric mapping demonstrates asymmetric uptake with Tc-99m ECD and Tc-99m HMPAO SPECT in normal brain. J Cereb Blood Flow Metab 2012; 32:190-8. [PMID: 21934696 PMCID: PMC3323300 DOI: 10.1038/jcbfm.2011.123] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Tc-99m ethyl cysteinate diethylester (ECD) and Tc-99m hexamethyl propylene amine oxime (HMPAO) are commonly used for single-photon emission computed tomography (SPECT) studies of a variety of neurologic disorders. Although these tracers have been very helpful in diagnosing and guiding treatment of neurologic disease, data describing the distribution and laterality of these tracers in normal resting brain are limited. Advances in quantitative functional imaging have demonstrated the value of using resting studies from control populations as a baseline to account for physiologic fluctuations in cerebral perfusion. Here, we report results from 30 resting Tc-99m ECD SPECT scans and 14 resting Tc-99m HMPAO scans of normal volunteers with no history of neurologic disease. Scans were analyzed with regions of interest and with statistical parametric mapping, with comparisons performed laterally (left vs. right), as well as for age, gender, and handedness. The results show regions of significant asymmetry in the normal controls affecting widespread areas in the cerebral hemispheres, but most marked in superior parietotemporal region and frontal lobes. The results have important implications for the use of normal control SPECT images in the evaluation of patients with neurologic disease.
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Affiliation(s)
- Benjamin H Brinkmann
- Mayo Systems Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota 55905, USA
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Hirsch LJ, Donner EJ, So EL, Jacobs M, Nashef L, Noebels JL, Buchhalter JR. Abbreviated report of the NIH/NINDS workshop on sudden unexpected death in epilepsy. Neurology 2011; 76:1932-8. [PMID: 21543734 DOI: 10.1212/wnl.0b013e31821de7de] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a devastating complication of epilepsy and is not rare. The NIH and National Institute of Neurological Disorders and Stroke sponsored a 3-day multidisciplinary workshop to advance research into SUDEP and its prevention. Parallel sessions were held: one with a focus on the science of SUDEP, and the other with a focus on issues related to the education of health care practitioners and people with epilepsy. This report summarizes the discussions and recommendations of the workshop, including lessons learned from investigations of sudden infant death syndrome (SIDS), sudden cardiac death, autonomic and respiratory physiology, medical devices, genetics, and animal models. Recommendations include educating all people with epilepsy about SUDEP as part of their general education on the potential harm of seizures, except in extenuating circumstances. Increasing awareness of SUDEP may facilitate improved seizure control, possibly decreasing SUDEP incidence. There have been significant advances in our understanding of the clinical and physiologic features of SIDS, sudden cardiac death, and SUDEP in both people and animals. Research should continue to focus on the cardiac, autonomic, respiratory, and genetic factors that likely contribute to the risk of SUDEP. Multicenter collaborative research should be encouraged, especially investigations with direct implications for the prevention of SUDEP. An ongoing SUDEP Coalition has been established to facilitate this effort. With the expansion of clinical, genetic, and basic science research, there is reasonable hope of advancing our understanding of SUDEP and ultimately our ability to prevent it.
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Affiliation(s)
- L J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Columbia University, New York, NY, USA.
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Wirrell EC, Grossardt BR, So EL, Nickels KC. A population-based study of long-term outcomes of cryptogenic focal epilepsy in childhood: cryptogenic epilepsy is probably not symptomatic epilepsy. Epilepsia 2011; 52:738-45. [PMID: 21320114 DOI: 10.1111/j.1528-1167.2010.02969.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare long-term outcome in a population-based group of children with cryptogenic versus symptomatic focal epilepsy diagnosed from 1980 to 2004 and to define the course of epilepsy in the cryptogenic group. METHODS We identified all children residing in Olmsted County, MN, 1 month through 17 years, with newly diagnosed, nonidiopathic focal epilepsy from 1980 to 2004. Children with idiopathic partial epilepsy syndromes were excluded. Medical records were reviewed to determine etiology, results of imaging and EEG studies, treatments used, and long-term outcome. Children were defined as having symptomatic epilepsy if they had a known genetic or structural/metabolic etiology, and as cryptogenic if they did not. KEY FINDINGS Of 359 children with newly diagnosed epilepsy, 215 (60%) had nonidiopathic focal epilepsy. Of these, 206 (96%) were followed for > 12 months. Ninety-five children (46%) were classified as symptomatic. Median follow-up from diagnosis was similar in both groups, being 157 months (25%, 75%: 89, 233) in the cryptogenic group versus 134 months (25%, 75%: 78, 220) in the symptomatic group (p = 0.26). Of 111 cryptogenic cases, 66% had normal cognition. Long-term outcome was significantly better in those with cryptogenic versus symptomatic etiology (intractable epilepsy at last follow-up, 7% vs. 40%, p < 0.001; seizure freedom at last follow-up, 81% vs. 55%, p < 0.001). Of those who achieved seizure freedom at final follow-up, 68% of the cryptogenic group versus only 46% of the symptomatic group were off antiepileptic medications (p = 0.01). One-third of the cryptogenic group had a remarkably benign disorder, with no seizures seen after initiation of medication, or in those who were untreated, after the second afebrile seizure. A further 5% had seizures within the first year but remained seizure-free thereafter. With the exception of perinatal complications, which predicted against seizure remission, no other factors were found to significantly predict outcome in the cryptogenic group. SIGNIFICANCE More than half of childhood nonidiopathic localization-related epilepsy is cryptogenic. This group has a significantly better long-term outcome than those with a symptomatic etiology, and should be distinguished from it.
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Affiliation(s)
- Elaine C Wirrell
- Division of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
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Kazemi NJ, Worrell GA, Stead SM, Brinkmann BH, Mullan BP, O'Brien TJ, So EL. Ictal SPECT statistical parametric mapping in temporal lobe epilepsy surgery. Neurology 2010; 74:70-6. [PMID: 20038775 DOI: 10.1212/wnl.0b013e3181c7da20] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Although subtraction ictal SPECT coregistered to MRI (SISCOM) is clinically useful in epilepsy surgery evaluation, it does not determine whether the ictal-interictal subtraction difference is statistically different from the expected random variation between 2 SPECT studies. We developed a statistical parametric mapping and MRI voxel-based method of analyzing ictal-interictal SPECT difference data (statistical ictal SPECT coregistered to MRI [STATISCOM]) and compared it with SISCOM. METHODS Two serial SPECT studies were performed in 11 healthy volunteers without epilepsy (control subjects) to measure random variation between serial studies from individuals. STATISCOM and SISCOM images from 87 consecutive patients who had ictal SPECT studies and subsequent temporal lobectomy were assessed by reviewers blinded to clinical data and outcome. RESULTS Interobserver agreement between blinded reviewers was higher for STATISCOM images than for SISCOM images (kappa = 0.81 vs kappa = 0.36). STATISCOM identified a hyperperfusion focus in 84% of patients, SISCOM in 66% (p < 0.05). STATISCOM correctly localized the temporal lobe epilepsy (TLE) subtypes (mesial vs lateral neocortical) in 68% of patients compared with 24% by SISCOM (p = 0.02); subgroup analysis of patients without lesions (as determined by MRI) showed superiority of STATISCOM (80% vs 47%; p = 0.04). Moreover, the probability of seizure-free outcome was higher when STATISCOM correctly localized the TLE subtype than when it was indeterminate (81% vs 53%; p = 0.03). CONCLUSION Statistical ictal SPECT coregistered to MRI (STATISCOM) was superior to subtraction ictal SPECT coregistered to MRI for seizure localization before temporal lobe epilepsy (TLE) surgery. STATISCOM localization to the correct TLE subtype was prognostically important for postsurgical seizure freedom.
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Affiliation(s)
- N J Kazemi
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Bell ML, Rao S, So EL, Trenerry M, Kazemi N, Stead SM, Cascino G, Marsh R, Meyer FB, Watson RE, Giannini C, Worrell GA. Epilepsy surgery outcomes in temporal lobe epilepsy with a normal MRI. Epilepsia 2009; 50:2053-60. [PMID: 19389144 PMCID: PMC2841514 DOI: 10.1111/j.1528-1167.2009.02079.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the long-term efficacy of anterior temporal lobectomy for medically refractory temporal lobe epilepsy in patients with nonlesional magnetic resonance imaging (MRI). METHODS We identified a retrospective cohort of 44 patients with a nonlesional modern "seizure protocol" MRI who underwent anterior temporal lobectomy for treatment of medically refractory partial epilepsy. Postoperative seizure freedom was determined by Kaplan-Meyer survival analysis. Noninvasive preoperative diagnostic factors potentially associated with excellent surgical outcome were examined by univariate analysis in the 40 patients with follow-up of >1 year. RESULTS Engel class I outcomes (free of disabling seizures) were observed in 60% (24 of 40) patients. Preoperative factors associated with Engel class I outcome were: (1) absence of contralateral or extratemporal interictal epileptiform discharges, (2) subtraction ictal single photon emission computed tomography (SPECT) Coregistered to MRI (SISCOM) abnormality localized to the resection site, and (3) subtle nonspecific MRI findings in the mesial temporal lobe concordant to the resection. DISCUSSION In carefully selected patients with temporal lobe epilepsy and a nonlesional MRI, anterior temporal lobectomy can often render patients free of disabling seizures. This favorable rate of surgical success is likely due to the detection of concordant abnormalities that indicate unilateral temporal lobe epilepsy in patients with nonlesional MRI.
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Affiliation(s)
- Michael L. Bell
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Satish Rao
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Elson L. So
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Max Trenerry
- Department of Neuropsychology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Noojan Kazemi
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - S. Matt Stead
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Gregory Cascino
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Richard Marsh
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Fredric B. Meyer
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Robert E. Watson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Gregory A. Worrell
- Department of Neurology and Division of Epilepsy and Electroencephalography, Mayo Clinic, Rochester, Minnesota, U.S.A
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So EL. Assessing Central Nervous System Symptoms. Clin Neurophysiol 2009. [DOI: 10.1093/med/9780195385113.003.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The major value and primary application of clinical neurophysiology is in the assessment and characterization of neurologic disease. Selection of appropriate studies for the problem of an individual patient requires a careful clinical evaluation to determine possible causes of the patient’s symptoms. The nature of the symptoms and the conclusions of the clinical evaluation are the best guides to appropriate use of clinical neurophysiologic testing.
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So EL, Sharbrough FW. Cerebral Function Monitoring. Clin Neurophysiol 2009. [DOI: 10.1093/med/9780195385113.003.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Intraoperative electrophysiologic monitoring of cerebral function during cardiovascular surgery requires a thorough knowledge of the effect of anesthetic agents on electrophysiologic signals. Although there are variations among anesthetic agents and their effects on the EEG, most of the agents produce similar changes that can be recognized and distinguished from the effects of ischemia. Success of the monitoring also depends heavily on the technical aspects of recording, such as the timescale of the EEG display and adjustment of the anesthetic agent used.
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So EL, Bainbridge J, Buchhalter JR, Donalty J, Donner EJ, Finucane A, Graves NM, Hirsch LJ, Montouris GD, Temkin NR, Wiebe S, Sierzant TL. Report of the American Epilepsy Society and the Epilepsy Foundation Joint Task Force on Sudden Unexplained Death in Epilepsy. Epilepsia 2009; 50:917-22. [DOI: 10.1111/j.1528-1167.2008.01906.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
This article highlights studies in three major domains of potential mechanisms of sudden unexplained death in epilepsy (SUDEP): cardiac, respiratory, and autonomic. Ictal cardiac arrest is a clinically rare but well-recognized potential mechanism of SUDEP. Studies have failed to identify preexisting cardiac electrophysiologic or structural abnormalities that distinguish SUDEP persons. Some degree of pulmonary congestion is a common autopsy finding, but severe pulmonary edema occurs very rarely with seizures. In contrast, periictal apnea and hypoxia occur commonly with generalized tonic-clonic seizures and, to a lesser degree, with complex partial seizures. There are several animal models of postictal respiratory arrest. Postictal respiratory arrest in audiogenic seizure mice can be induced by serotonin receptor inhibition or prevented by selective serotonin reuptake inhibitor (SSRI) drugs. Reduced heart rate variability occurs in patients with refractory epilepsy and can be induced in animal seizure models, but its precise role in predisposing persons to sudden death requires further investigation.
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Affiliation(s)
- Elson L So
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Tan KM, Britton JW, Buchhalter JR, Worrell GA, Lagerlund TD, Shin C, Cascino GD, Meyer FB, So EL. Influence of subtraction ictal SPECT on surgical management in focal epilepsy of indeterminate localization: A prospective study. Epilepsy Res 2008; 82:190-3. [DOI: 10.1016/j.eplepsyres.2008.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 08/08/2008] [Accepted: 08/20/2008] [Indexed: 10/21/2022]
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O'Brien TJ, Mosewich RK, Britton JW, Cascino GD, So EL. History and seizure semiology in distinguishing frontal lobe seizures and temporal lobe seizures. Epilepsy Res 2008; 82:177-82. [PMID: 18804957 DOI: 10.1016/j.eplepsyres.2008.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 07/28/2008] [Accepted: 08/10/2008] [Indexed: 10/21/2022]
Abstract
This study aimed to determine the reliability of clinical history and seizure semiology for distinguishing between frontal lobe seizures (FLS) and temporal lobe seizures (TLS). FLS patients (n=23) were consecutively identified through an epilepsy surgery database. TLS patients (n=27) were selected randomly from 238 patients who had undergone temporal lobe surgery for epilepsy. The criterion standard for seizure localization was the location of resective epilepsy surgery that controlled seizures for a minimum of 2 years. Blinded comparisons of 13 historical information items (HII) and 19 video-recorded semiologic features (VSF) were made. We identified 3 HII (sex, history of febrile convulsions, and history of generalized tonic-clonic seizures) and 2 VSF (fencing posturing and postictal confusion) that significantly distinguished between FLS and TLS. The multivariate analysis model correctly identified 87% of FLS patients and 74% of TLS patients. No single HII or VSF is sufficient for distinguishing between FLS and TLS. A model integrating multiple HII and VSF may assist in this differentiation, but some patients still may be misclassified.
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Affiliation(s)
- Terence J O'Brien
- Department of Medicine, Surgery, and Neurology, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia
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Buechler RD, Rodriguez AJ, Lahr BD, So EL. Ictal scalp EEG recording during sleep and wakefulness: Diagnostic implications for seizure localization and lateralization. Epilepsia 2008; 49:340-2. [PMID: 17888077 DOI: 10.1111/j.1528-1167.2007.01320.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To determine the localizing value of electroencephalography (EEG) for seizures during sleep versus seizures during wakefulness, we compared scalp EEG for 58 seizures that occurred during sleep with 76 seizures during wake in 28 consecutive patients with temporal lobe epilepsy. Regression analysis showed that seizures during sleep are 2.5 times more likely to have focal EEG onset (p = 0.01) and 4 times more likely to correctly localize seizure onset (p = 0.04) than seizures during wake. EEG seizure onset preceded clinical onset by a longer duration in sleep seizures (mean, 4.69 s) than in wake seizures (mean, 1.23 s; p < 0.01). Sleep seizures showed fewer artifacts, but the difference was not significant (p = 0.07). For temporal lobectomy candidates undergoing video-EEG monitoring, the recording of seizures during sleep may be favored.
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Affiliation(s)
- Robbie D Buechler
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Rodriguez AJ, Buechler RD, Lahr BD, So EL. Temporal lobe seizure semiology during wakefulness and sleep. Epilepsy Res 2007; 74:211-4. [PMID: 17448637 DOI: 10.1016/j.eplepsyres.2007.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 03/09/2007] [Accepted: 03/19/2007] [Indexed: 11/24/2022]
Abstract
We used regression analysis to compare the semiologic features of temporal lobe seizures that occur during sleep (TLS-S) and wake (TLS-W) in the same patient. Most semiologic features correctly lateralized seizure activity during either sleep or wake. No significant differences were found between TLS-S and TLS-W in the 18 semiologic features analyzed. The diagnostic value of TLS-S semiology is similar to that of TLS-W semiology.
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Abstract
The cause of sudden unexplained death in epilepsy (SUDEP) is still elusive, despite multiple studies over the past few decades. This review assesses recent progress in the understanding of risk factors (situations that predispose patients to SUDEP) and terminal events (events immediately associated with death) that potentially contribute to SUDEP. Recent studies strongly support a close relationship between seizure episodes (especially generalized convulsions) and SUDEP. The lethal nature of some seizure-induced cardiorespiratory events has been documented fortuitously in rare patient cases, and these events have been consistently reproduced in SUDEP animal models. Nonetheless, SUDEP likely does not have a single cause, and risk factors identified thus far may vary in importance among persons with epilepsy. In the absence of a complete understanding of the pathophysiologic mechanisms underlying SUDEP, potential preventive measures for high-risk patients are offered for consideration. Seizure control is most important for reducing SUDEP risk. Circumstantial data suggest that heightened supervision of patients with frequent seizures may be beneficial. Relatively simple interventions may be sufficient to interrupt potentially lethal events such as periictal suffocation or apnea. However, application of these preventive measures to all epilepsy patients has not been proven to substantially reduce the rate of SUDEP. Additional clinical and laboratory investigations are needed to identify and confirm pathogenic factors and preventive measures.
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Affiliation(s)
- Elson L So
- Section of Electroencephalography, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Seizure semiology has been the foundation of clinical diagnosis of seizure disorders. This article discusses the value and the limitations of behavioral features of seizure episodes in localizing seizure onset. Studies have shown that some semiologic features of seizures are highly accurate in the hemispheric lateralization and lobar localization of seizures. There is good agreement between blinded reviewers in lateralizing video-recorded seizures in temporal lobe and extratemporal lobe epilepsies. However, seizure semiology alone should not be used to determine the site of seizure onset. Each semiologic feature may falsely localize seizure onset. Seizure semiology in some patients may signify the site of seizure propagation rather than origination. Moreover, seizure semiology may not be as reliable in multifocal epilepsies as it is in unifocal epilepsies. Many semiologic features of seizures of adults are often missing in seizures of children. Seizure semiology should be analyzed and integrated with EEG and neuroimaging data to localize the seizure focus. A sample of the recorded seizures should be shown to the patient's relatives or friends to verify that it is representative of habitual seizures.
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Affiliation(s)
- Elson L So
- Section of Electroencephalography, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wetjen NM, Cascino GD, Fessler AJ, So EL, Buchhalter JR, Mullan BP, O'Brien TJ, Meyer FB, Marsh WR. Subtraction ictal single-photon emission computed tomography coregistered to magnetic resonance imaging in evaluating the need for repeated epilepsy surgery. J Neurosurg 2006; 105:71-6. [PMID: 16874891 DOI: 10.3171/jns.2006.105.1.71] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to determine whether ictal single-photon emission computed tomography (SPECT) is useful in localizing the site of seizure onset in patients in whom surgery for intractable epilepsy failed and who are being considered for repeated surgery.
Methods
Subtraction ictal SPECT coregistered to magnetic resonance imaging (SISCOM) studies were retrospectively analyzed in 58 patients who were being evaluated for possible repeated resection for intractable partial epilepsy between January 1, 1996, and October 31, 1999. All patients had persistent seizures subsequent to an initial resection and underwent another excision. The SISCOM-demonstrated abnormalities were classified as concordant, discordant, or indeterminate, compared with the localization of the epileptogenic zone revealed on video electroencephalography monitoring. The ability of SISCOM to predict operative outcome was also determined in patients who had undergone repeated surgical procedures.
The SISCOM studies revealed a localized hyperperfused alteration in 46 (79%) of 58 patients. Forty-one (89%) of these 46 patients had a SISCOM-demonstrated alteration in the hemisphere of the previous epilepsy surgery. Imaging changes in 33 (72%) of the 46 patients were at the site of the previous focal cortical resection. Eight (17%) of the 46 had SISCOM-demonstrated abnormalities remote from the lobe in which surgery had been performed but in the ipsilateral hemisphere. The hyperperfusion focus was in the contralateral hemisphere in the remaining five patients (11%). The site of the epileptogenic zone was concordant with the SISCOM focus in 32 (70%) of 46 patients. Twenty-six patients underwent repeated resection and were followed up for a mean of 44 months thereafter; 11 of these patients (42%) had a significant reduction in seizure tendency. Only five patients (19%) were seizure free. Ten (50%) of 20 patients with a concordant SISCOM focus compared with none (0%) of three patients with a discordant focus had a favorable surgical outcome (p = 0.23).
Conclusions
The SISCOM method might be useful in the evaluation of, and the surgical planning for, patients with intractable partial epilepsy in whom previous resective treatment has failed and who are being considered for reoperation.
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Affiliation(s)
- Nicholas M Wetjen
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Schraeder PL, Delin K, McClelland RL, So EL. Coroner and medical examiner documentation of sudden unexplained deaths in epilepsy. Epilepsy Res 2006; 68:137-43. [PMID: 16423504 DOI: 10.1016/j.eplepsyres.2005.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2005] [Revised: 10/06/2005] [Accepted: 10/19/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Prevalence data for sudden unexplained death in epilepsy (SUDEP) are hampered by its underuse as a final diagnosis on death certificates in appropriate cases. Few data exist about how coroners (COs) and medical examiners (MEs) in the United States use the diagnosis of SUDEP. METHODS A survey instrument that addressed demographics, professional background, annual cases of epilepsy, seizure history, percentage of post-mortem examinations, cause of death, and use of SUDEP as a diagnosis was sent to all COs and MEs in the United States. Unadjusted comparisons between categorical variables used chi2 tests. A multiple regression model examined the odds of respondents considering SUDEP to be a valid diagnosis. RESULTS Of 2995 surveys, 80.7% went to COs and 19.3% to MEs. The response rate was 15.9% for COs and 21.8% for MEs. Acknowledgment of SUDEP as a valid entity was greatest among pathologists (83.5%) versus other physicians and non-physicians (P< .001) and correlated with higher autopsy rates and seeing more cases of epilepsy. In actual practice, SUDEP was not used routinely as a death certificate diagnosis in most cases with no cause of death found at autopsy by any group in the survey regardless of title, educational background, location, autopsy rate, or number of seizure cases seen annually. CONCLUSIONS SUDEP appears to be an underused final diagnosis by COs and MEs throughout the United States. There is a need to educate officials at all levels about this diagnosis in persons who have epilepsy with no other cause of death.
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Affiliation(s)
- Paul L Schraeder
- Department of Neurology, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA 19102, USA
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Abstract
BACKGROUND Previous studies of injuries due to epileptic seizures predominantly involved patients with intractable epilepsy. These studies may have overestimated the risk of injuries in persons with epilepsy. METHODS Patients consisted of 247 Rochester, MN, residents who were diagnosed with epilepsy between 1975 and 1984. Seizure-related injuries were defined as any injury, other than orolingual trauma, resulting from a seizure, sufficient for the patient to seek medical attention or for injury occurrence to be determined during the course of medical care. To identify risk factors for injury, characteristics of patients with seizure-related injury were compared with those without injury. RESULTS During a total of 2,714 patient-years of follow-up, 62 seizure-related injuries were identified in 39 patients (16%, one injury in every 44 person-years). Most injuries involved cranial soft tissue contusions or lacerations (79%). The majority of seizure-related injuries (82%) occurred during generalized convulsive seizures. Univariate analyses identified five potential risk factors for seizure-related injury: greater number of antiepileptic drugs used, less independent living situation, higher Rankin score, history of generalized convulsive seizures or drop attacks, and higher seizure frequency score. Seizure frequency, however, was the only significant risk factor identified by multivariate analysis (p < 0.001; relative risk, 1.33). CONCLUSIONS This population-based study shows that seizure-related injuries are infrequent and generally of minor severity. In most epilepsy patients, excessive restriction of daily activities to avoid injury is unnecessary. Effective seizure control reliably reduces the risk of seizure-related injuries.
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Affiliation(s)
- N D Lawn
- Section of Electroencephalography, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Siegel AM, Cascino GD, Meyer FB, McClelland RL, So EL, Marsh WR, Scheithauer BW, Sharbrough FW. Resective reoperation for failed epilepsy surgery: Seizure outcome in 64 patients. Neurology 2004; 63:2298-302. [PMID: 15623690 DOI: 10.1212/01.wnl.0000147476.86575.a7] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the surgical outcome and factors of predictive value in patients undergoing reoperation for intractable partial epilepsy. METHODS The authors retrospectively studied the operative outcome in 64 consecutive patients who underwent reoperation for intractable partial epilepsy. Demographic data, results of comprehensive preoperative evaluations, and the seizure and neurologic outcome after reoperation were determined. All patients were followed a minimum of 1 year subsequent to their last operative procedure. RESULTS Fifty-three patients had two surgeries, and 11 patients had three or more operations. The first surgery involved a lesionectomy (n = 33), "nonlesional" temporal lobe resection (n = 28), and a "nonlesional" extratemporal resection (n = 3). The mean duration between the first and second procedure was 5.5 years. Fifty-five patients underwent an intralobar reoperation, whereas nine had a resection of a different lobe. After reoperation, 25 patients (39%) were free of seizure, 6 patients (9%) had rare seizures, 12 patients (19%) had a worthwhile improvement, and 21 patients (33%) failed to respond to surgery. Predictors of seizure-free outcome were age at seizure onset >15 years (p = 0.01), duration of epilepsy < or =5 years at the time of initial surgery (p = 0.03), and focal interictal discharges in scalp EEG (p = 0.03). Using a logistic regression model, two significant predictors emerged: duration of epilepsy < or =5 years (odds ratio, 3.18; p = 0.04) and preoperative focal interictal discharge (odds ratio, 4.45; p = 0.02). Complications of reoperation included visual field deficits (n = 9), wound infection (n = 2), subdural hematoma (n = 1), and hemiparesis (n = 1). CONCLUSION Reoperation may be an appropriate alternative form of treatment for selected patients with intractable partial epilepsy who fail to respond to initial surgery.
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MESH Headings
- Adolescent
- Adult
- Age of Onset
- Brain/abnormalities
- Brain Neoplasms/complications
- Brain Neoplasms/surgery
- Child
- Child, Preschool
- Electroencephalography
- Epilepsies, Partial/diagnosis
- Epilepsies, Partial/epidemiology
- Epilepsies, Partial/etiology
- Epilepsies, Partial/pathology
- Epilepsies, Partial/surgery
- Female
- Follow-Up Studies
- Gliosis/complications
- Gliosis/surgery
- Humans
- Infant
- Infant, Newborn
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Postoperative Complications/epidemiology
- Recurrence
- Reoperation
- Retrospective Studies
- Risk Factors
- Time Factors
- Tomography, Emission-Computed, Single-Photon
- Tomography, X-Ray Computed
- Treatment Outcome
- Tuberous Sclerosis/complications
- Tuberous Sclerosis/surgery
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Affiliation(s)
- A M Siegel
- Division of Epilepsy, Mayo Clinic, Rochester, MN 55905, USA. gcasc
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Cascino GD, Buchhalter JR, Sirven JI, So EL, Drazkowski JF, Zimmerman RS, Raffel C. Peri-ictal SPECT and surgical treatment for intractable epilepsy related to schizencephaly. Neurology 2004; 63:2426-8. [PMID: 15623720 DOI: 10.1212/01.wnl.0000147262.70507.76] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The authors evaluated four patients with schizencephaly who underwent subtraction ictal SPECT coregistered to MRI (SISCOM) prior to epilepsy surgery. Three patients had a SISCOM alteration that was concordant with the epileptic brain tissue. Two of these patients were rendered seizure-free and one individual experienced a significant reduction in seizures. The patient with an indeterminate SISCOM had an unfavorable outcome. SISCOM is useful in evaluating patients with schizencephaly for epilepsy surgery.
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Affiliation(s)
- G D Cascino
- Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
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Abstract
Intracranial EEG in a 33-year-old man with epilepsy with a history of falls and injuries showed seizure onset in the right posterior parietal region. Electrical stimulation of the region reproduced sudden estrangement of the left lower extremity. EMG and video recordings showed no alteration of extremity tone during the seizure, but his gait halted before he fell. Ictal asomatognosia may be a cause of falls in patients with epilepsy.
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Affiliation(s)
- Elson L So
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Pandian JD, Cascino GD, So EL, Manno E, Fulgham JR. Digital video-electroencephalographic monitoring in the neurological-neurosurgical intensive care unit: clinical features and outcome. ACTA ACUST UNITED AC 2004; 61:1090-4. [PMID: 15262740 DOI: 10.1001/archneur.61.7.1090] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prolonged electroencephalographic (EEG) recordings in the neurological-neurosurgical intensive care unit (NICU) may be performed in patients with status epilepticus, repetitive seizure activity, or an encephalopathy with or without seizures. The electroclinical correlation and neurological outcome of patients undergoing digital video-EEG monitoring (DVEEG) in the NICU has not been determined. OBJECTIVES To evaluate the clinical utility and prognostic importance of the DVEEG in the NICU. METHODS We retrospectively evaluated 105 patients who underwent DVEEG in the NICU at the Mayo Clinic, Rochester, Minn, between January 1, 1994, and July 31, 2001. All patients had a routine EEG recording performed prior to DVEEG. RESULTS The mean age of the patients at the time of the DVEEG was 54 years (age range, 16-88 years). The mean duration of the DVEEG was 2.9 days (range, 1-17 days). Forty-four patients (42%) had a severe encephalopathy (Glasgow Coma Scale score, <8) at the time of the DVEEG. Forty-five patients (42.8%) had generalized convulsive status epilepticus, 19 patients (18.1%) had nonconvulsive status epilepticus, and 7 patients (6.7%) had epilepsia partialis continua. The mean duration of follow-up was 7 months (range, 1-54 months). The outcome in 84 patients included death in 38 patients, severe neurological deficits, that is, bed bound and needs support for activities of daily living, in 6 patients, and a vegetative state in 3 patients. Fifteen individuals had no neurological impairment during follow-up. Refractory status epilepticus (P<.003), hypoxic-ischemic encephalopathy (P<.004), and multiple cerebral infarcts (P<.003) were the factors associated with increased mortality in univariate analysis. With multivariate logistic regression analysis only the presence of multiple strokes (P<.03; odds ratio, 5.62) was predictive of mortality. CONCLUSIONS Continuous EEG monitoring is essential in the diagnosis and treatment of refractory status epilepticus or an encephalopathy with seizures in the NICU. A minority of these patients, however, experienced a favorable neurological outcome.
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Affiliation(s)
- Jeyaraj D Pandian
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
Single photon emission computed tomography is appropriate for peri-ictal imaging inpatients with focal epilepsy being considered for surgical treatment.
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Affiliation(s)
- Gregory D Cascino
- Department of Neurology, Division of Epilepsy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
PURPOSE Ictal single-photon emission computed tomography (SPECT) may be a reliable indicator of the ictal onset zone in patients with intractable partial epilepsy who are being considered for epilepsy surgery. The rationale for the illustrated case report is to evaluate the use of an innovation in SPECT imaging in a patient with nonlesional extratemporal epilepsy. METHODS We investigated the presurgical evaluation and operative outcome in a patient with intractable partial epilepsy. The ictal semiology indicated a "hypermotor" seizure with bipedal automatism. The electroclinical correlation and magnetic resonance imaging (MRI) did not suggest the appropriate localization of the epileptogenic zone. A subtraction periictal SPECT coregistered to MRI (SISCOM) was peformed. RESULTS SISCOM revealed a region of localized hyperperfusion in the right supplementary sensorimotor area. Chronic intracranial EEG monitoring confirmed the relationship between the localized SISCOM alteration and the ictal onset zone. The patient was rendered seizure free after surgical treatment. CONCLUSIONS SISCOM may be used to identify potential candidates for surgical treatment of nonlesional extratemporal epilepsy. Periictal imaging may also alter the strategy for intracranial EEG recordings and focal cortical resection.
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Affiliation(s)
- Gregory D Cascino
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Vadlamudi L, So EL, Worrell GA, Mosewich RK, Cascino GD, Meyer FB, Lesnick TG. Factors underlying scalp-EEG interictal epileptiform discharges in intractable frontal lobe epilepsy. Epileptic Disord 2004; 6:89-95. [PMID: 15246953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
AIMS Scalp-EEG interictal epileptiform discharges (IEDs) may be less predictive of the outcome of frontal lobe epilepsy surgery than of temporal lobe epilepsy surgery. We identified factors associated with the location of scalp-EEG IEDs in intractable frontal lobe epilepsy. METHODS Ten factors were assessed in a retrospective review of 53 patients with either concordant (frontal lobe seizure focus) or discordant (generalized or outside frontal seizure focus) IED or both, who had excellent surgical outcomes. The Fisher exact test and the Wilcoxon rank sum test determined statistically significant associations. RESULTS Thirty-six patients (68%) had concordant IED, 24 (45%) discordant IED, and 17 (32%) both. Younger age at onset was significantly associated with discordant IED (mean, 7.5 years versus 17 years for patients without discordant IED; P < 0.01), whereas duration of epilepsy was not. Seizure foci at the frontal convexity were associated with concordant IED. About 72% of patients with a convexity seizure focus had concordant IED, compared with only 33% of patients with mesial frontal foci having concordant IED (P = 0.06). CONCLUSIONS Early seizure onset in intractable frontal lobe epilepsy is associated with IEDs discordant with seizure focus. Frontal convexity seizure foci are more likely than mesial frontal seizure foci to be associated with concordant discharges.
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Affiliation(s)
- Lata Vadlamudi
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
Epilepsy surgery has emerged as an important option in the treatment of children with epilepsy that is refractory to antiepileptic drug management. The cornerstone of successful surgery is accurate localization of the brain region of seizure onset. Traditional techniques of seizure onset localization, e.g. surface electroencephalography (EEG) recording and magnetic resonance imaging (MRI), allow accurate localization in a significant number of patients. When the focus of seizure onset is not apparent from these non-invasive techniques, other methods of localization, e.g. intracranial EEG recording, may be needed before resection of the focus. Single-photon emission computed tomography (SPECT) is a nuclear medicine blood-flow technique that has been used to identify a region of epileptogenic brain associated with low blood flow in the resting state (interictal SPECT) or increased blood flow at the time of seizure activity (ictal SPECT). This report describes the validation and utility of a computer-assisted method of subtracting the interictal from the ictal SPECT scans and co-registering the difference image on the MRI. This method, called subtraction ictal SPECT co-registered on MRI (SISCOM), is used in guiding the location and the extent of intracranial electrode implantation, or in obviating the need for the implantation in some cases.
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O'Brien TJ, So EL, Cascino GD, Hauser MF, Marsh WR, Meyer FB, Sharbrough FW, Mullan BP. Subtraction SPECT Coregistered to MRI in Focal Malformations of Cortical Development: Localization of the Epileptogenic Zone in Epilepsy Surgery Candidates. Epilepsia 2004; 45:367-76. [PMID: 15030499 DOI: 10.1111/j.0013-9580.2004.54703.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine the extent to which periictal subtraction single-photon emission computed tomography (SPECT) may improve detection and definition of the epileptogenic zone in patients with focal malformations of cortical development (MCDs). METHODS Subtraction SPECT coregistered to magnetic resonance (MR) images (SISCOM) were constructed for 22 consecutive patients with focal MCDs who underwent periictal SPECT injection (18 ictal and four postictal). In the 17 patients who had epilepsy surgery, concordance between the site of SISCOM localization and site of surgical resection was determined by coregistration of SISCOM images with postoperative MRIs. RESULTS SISCOM images were localizing in 19 (86%) patients, including eight of the 10 with nonlocalizing MRI. Concordance of SISCOM localization was 91% with MRI localization, 93% with scalp ictal EEG localization, and 100% with intracranial EEG localization. Eight patients whose SISCOM localization was concordant with the surgical resection site had lower postoperative seizure frequency scores (SFSs; p = 0.04) and greater postoperative improvement in SFSs (p = 0.05) than the nine patients whose SISCOM was either nonconcordant or nonlocalizing. On multiple regression analysis, a model combining SISCOM concordance with surgical resection site and extent of MRI lesion resection was predictive of postoperative SFS (R2 = 0.47; p = 0.03). CONCLUSIONS Periictal subtraction SPECT using the SISCOM technique provides useful information for seizure localization in patients with focal MCDs, even when MRI is nonlocalizing.
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Affiliation(s)
- Terence J O'Brien
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia
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Tigaran S, Cascino GD, McClelland RL, So EL, Richard Marsh W. Acute postoperative seizures after frontal lobe cortical resection for intractable partial epilepsy. Epilepsia 2003; 44:831-5. [PMID: 12790897 DOI: 10.1046/j.1528-1157.2003.56402.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the incidence and prognostic importance of acute postoperative seizures (APOSs) occurring in the first week after a focal corticectomy in patients with partial epilepsy of frontal lobe origin. METHODS We retrospectively evaluated 65 patients who underwent a frontal lobe cortical resection for intractable partial epilepsy between April 1987 and December 2000. All patients were followed up for a minimum of 1 year after surgery. RESULTS APOSs occurred in 17 (26%) patients. None of the following factors was shown to be significantly associated with the occurrence of APOSs: gender, duration of epilepsy, etiology for seizure disorder, use of subdural or depth electrodes, surgical pathology, or postoperative risk factor for seizures. Patients with APOSs were older at seizure onset and at the time of surgery (p = 0.003 and p = 0.05, respectively). At last follow-up, patients who had APOSs had a seizure-free outcome similar to that of individuals without APOSs (47.1% vs. 50.0%; p = 0.77). Patients with APOSs appeared less likely to have a favorable outcome [i.e., fewer than three seizures per year and >95% decrease in seizure activity (58.8 vs. 70.8%; p = 0.35)]. This result may not have reached statistical significance because of the sample size. No evidence suggested that precipitating factors or the timing of APOSs was an important prognostic factor. CONCLUSIONS The presence of APOSs after frontal lobe surgery for intractable epilepsy does not preclude a significant reduction in seizure tendency. These findings may be useful in counseling patients who undergo surgical treatment for frontal lobe epilepsy.
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Affiliation(s)
- Simona Tigaran
- Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905, USA
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